Student Reports on Finals 2010

Student Reports on Finals at Bristol 2010

Written by students for students Students attending my revision courses are asked each year to give me feedback on their experiences in the clinical part of their exams and for comments about the courses. This helps keep the courses up to date and as relevant as possible and also helps to give subsequent cohorts of students a flavour of whats expected. Please note that any answers suggested by students have not been checked for accuracy. Health warning 1: Exams change each year Examiners arent stupid. They frequently change the content of clinical exams. Every year students email me with comments like: Everyone got a bit of a shock in finals this year because for the first time in years the examinations changed from day to day! So dont confine your learning to things that came up last year or the year before. Yes, it is useful to be aware of the exam format and favourite questions, but aim to pick up and practise the skills you will need for the job you will be doing. Health warning 2: Reports can be misleading Writing down what happened in the exam can be quite cathartic- a particularly useful way of off-loading all the stress- and so may not always give a balanced account, as people tend to emphasise the bits they found tricky. Take all the cases that people write about here with a pinch of salt. They seem like nightmares when you read them but in the actual exam you just deal with it and get on with it. I looked at the past questions before my exams and freaked myself out. Just look at these things to get an idea about stuff to include in your revision. I advise AGAINST looking at these things the day before your exam. Health warning 3: Remember the standard thats expected In terms of the clinical exams I thought Id done ok but really didnt feel Id done enough to do any more than pass. It turned out that I got As. I think the lesson is dont get caught up in the Finals circus. They want safe junior doctors who can examine patients and elicit signs, not their next registrar. Health warning 4: Dont get obsessed with exam marking schedules The biggest task is just to relax and manage each station as if you are managing this patient in real life. Some people practised the whole year from textbooks, but still failed and I think this is because they get bogged down by memorising lists of things they have to do to get marks, instead of thinking what it is they need to know and what they should do based on what information they have. I know I didn't get to do everything on each mark sheet, but I showed that I knew how to manage patients safely and that it was becoming second-nature to me. For me, this came about by being in clinics and practising many of these things in real life. Health warning 5: Trust your own judgement My biggest advice is not to listen to students who went before you or to let people freak you out. You always know more than you think you do and will be amazed with what comes out!

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Student Reports on Finals 2010 Student report

Hi Dr. Clarke, I had my final long case yesterday and so thought I'd feedback while still fresh! There was a logistical problem with one of my examiners being in theatre when I arrived for my exam and so I had to wait for 30mins before they found another. The first patient had been discharged but a second one was located quickly. He was a 45 year old man with hepatocellular carcinoma which was causing recurrent right upper quadrant pain requiring admissions. The history took me longer than I had planned and practised (probably around 35 mins) but he had quite an indepth story. I decided to explore the pain, jaundice, ascites and asked about clotting abnormalities and anaemia. Then I covered risk factors (he was hep C positive from either a 1980's transfusion or from the numerous tattoos he had) and a quick sexual history. I then ruled out cholecystitis, pyelonephritis and bowel obstruction. He had just been diagnosed with DM type II and so we briefly spoke about and complications. My examination was ok but a little rushed at the end due to time. I spent longer on the GI system and made sure I checked his feet and did lower limb neuro with lots of sensation testing. I had three minutes to gather those thoughts and was then asked to present. I clarified whether they wanted a presentation or summary and they said "A summary please because we've just watched you take the history!" Questions: 1) "He told you the diagnosis of hepatocellular carcinoma; what would your differentials have been?" To which I replied "Well I ruled out gall pathology by asking this..., urinary by asking this... and bowel by asking this...." 2) "What would your investigations be if this man came in on take?" I decided to start from management to show I understood the patient's situation so said "My management would be oxygen and pain relief but my investigations would be to take blood to look for anaemia in the full blood count, and any intercurrent infection causing decompensation through the white cell count and c reactive protein. I would check his serum glucose also. Obviously I would look at the liver function tests for derangement and to see if there was an obstructive picture. I would add clotting also to look for a prolonged prothrombin time. I would look at the urea and electrolytes for any evidence of hepatorenal syndrome and organise an ultrasound scan to look at the liver parenchyma and rule out gall stones. If I knew it was Hepatocellular carcinoma I would organise a CT scan to stage and grade." 3) "If this patient came in at night and you couldn't get those imaging services what would you tell the patient?" I didn't really understand this question and should have asked to rephrase it. I replied "I would have to be straight and explain that we couldn't be certain without imaging until the morning but that I would give him pain relief so that he is comfortable and taking bloods to get the investigations underway."

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Student Reports on Finals 2010 I think it went ok. There was a lot to get through and the examination was rushed but it showed that I'd practised a lot. My advice would be: - Time management when practising because you need to have some room for complications on the day - Have a good opening chat: Thank you for seeing me, I am X, this will take 60 minutes, sorry if I have to rush through. Can I get you to confirm your full name, DOB, age and occupation. Then you should be a bit more relaxed!- Try to forget the examiners and act like the F1 with a patient to treat - Put in little comments like "Yes I know the ascites is uncomfortable/Have you had fluid taken off?" to show you've seen patients like this before. - Make an opportunity of each question to show your knowledge but also your person skills. - Thank the examiners. Thanks for your great revision courses!

Student report My patient was a 71-year-old female with ulcerative colitis. She was an elective presented for a regimen of IV steroids due to exacerbation of UC. She was diagnosed with the condition a year ago secondary to the use of NSAIDs (Ibuprofen and Diclofenac) and Tramadol for a tapped femoral nerve. The patient has been on a modified diet, trialled 5-ASAs and was now trialling Hydrocortisone. In the past few weeks the patient had also been experiencing itchy eyes, swelling and tenderness of MCP joints bilaterally with a rash on her neck. She had ? erythema nodosum as a child, suffered with psoriasis with a +ve family history of the same and lost one sister to bullous pemphigoid and myasthenia gravis. She was infertile secondary to polycystic ovaries and had been through 6x Dilation and Curettages and an appendectomy 20 years ago. The examiners could not have been nicer to me and after I presented the patient they asked the following questions: Alright, if this lady turned up on the ward last year with her symptoms, what would your immediate investigations be ABC if patient acutely unwell, FBC looking for anaemia and infection, Us and Es for any electrolyte imbalance... ...Such as... Low potassium Is she on anything at the moment to guard against this Yes, Sando K Why else might she be on Sando K? Because she is on a diuretic for bilateral pedal oedema Good... please continue with your investigations

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Student Reports on Finals 2010 LFTs as a baseline for any future treatment I might begin, abdo x-ray for signs of bowel obstruction, Ba enema and serology for HLA-B27 due to her personal and family history of seronegative spondyloarthropathies What other investigations would you do to rule out other differentials... Stool culture for bacterial causes of diarrhoea? Good... Who would you want to get involved early in the management of a patient with UC Surgeons if considering total colectomy, stoma care nurse, GP and Practice nurses? Who else?... I was racking my brain at this stage... couldnt think who else... I wanted to say physios / HCAs, car parking attendants...I had no idea and the Consultant saw the pause and said... They wear blue outfits often with white collars... Arghh, dieticians? ... lol. Yes... Lol...As you mentioned, the patient has been trialled on 5-ASAs and Hydrocortisone and is reluctant to have a colectomy. What third line treatment can she have? Laxatives if she becomes constipated, probiotics, high protein diet...? And any immunotherapy? Yes, Infliximab Yes. Good... What things in her past may have also been a contributing factor to the UC besides the drugs? Appendectomy causing adhesions, infections following the D and Cs and HLA-B27 status And her fertility? PCOS? I had no idea they were related so just guessed Yes, that is a hard question though so I wont push anymore on that. Thank you for your time 4

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Student Reports on Finals 2010 Student report Dear Dr Clarke, Just wanted to tell you that I enjoyed your revision course and it helped me a lot. As a side note, if I were to give advice to future final years regarding attending revision course, I would have told them to attend one that is not too close to exams, or even at the beginning of the final year as I think it might be more beneficial and will give an overview of the important things one need to focus on and to go through all the post course notes. Long case: I had a stroke patient who had 6 TIAs and 2 DVTs previously and a hole in the heart; repaired recently. I forgot a few important questions like visual involvement, and which side the previous TIA affected (but I didnt think I could have delved into 6 TIAs in 1 hour). He had weakness, dysdiadochokinesis and past pointing. And did not examine his gait. Questions at the end were what would I have told the patient regarding driving? The other question (and the examiner said he didnt expect me to know the answer) was did I think the TIA/ stroke could be related to the DVT. But I guess I did sufficient to pass - examination needs to be slick. EMQ: all were pick the answer from a choice of 26 options. The 1st paper was more basic questions that it was too difficult eg: 5 signs of myocarditis. The 2nd paper was more like the questions you would find in Pastest. Both paper I was tight for time, very difficult. I was very disappointed to find that the one question I answered confidently was one on epidemiology which I spent about 10 minutes studying out of the WHOLE year. DOSCE: They changed the format this year. Lots and lots and lots of questions. There were 12 topics: ECG, surgical signs, dermatology, medical signs, ophthalmology, video on psychiatry consultation, ward round note taking (cant remember the others, sorry). There were a lot of videos, like patient describing visual loss, fasciculation, myotonic dystrophy, CN3 lesion, Chvosteks sign, clonus. Pictures were of things like scleroderma, Terrys nails (I think). Make sure to listen properly since you cant replay the video as it is done in the lecture theatre. OSCE: 1. 2. 3. venepuncture (read question properly) palliative care (telling daughter mom is not going to survive this admission and discuss DNAR) ENT exam plus picture of something, upper limb neuro exam (I had a patient with symptoms of Parkinsons in right arm but was complaining of left elbow pain) write up drugs for patient with acute asthma correct drug chart (make sure to practise Dr Levys examples in 10 minutes as it was just as bizarre as the examples) GALS screen on woman with RA in hands (I was asked if I thought it was active or not) visually impaired patient with symptoms of UTI (had to explain how to do MSU, take him to toilet, and explain management-need to repeat so that he understood) GP consultation with patient new diagnosis of asthma (got out of her that it was more work related-hairdresser) PR exam on mannequin and to document findings Portfolio station; very relaxing, asked what did I think of the 5

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Student Reports on Finals 2010 portfolio and discussed one of the cases Take a BP on the examiner and Ophthalmology; ping pong balls (make sure to practise!) ; 5 min each CVS examination on a patient who had mid-sternotomy scar and murmur in apex area; his heart sounds was very soft but I think he had mitral regurgitation (the examiner didnt believe me when I said I could not feel his apex beat; although when I spoke to another student, he said he couldnt feel it either) Discharge summary (which was impossible to do as I couldnt read the handwriting). All I managed to write was GP address and presenting complaint and some investigations and signed it.

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Student report Dear Dr Clarke, Here is some information about the Bristol finals 2010. If you do want to use this information for your website feel free to edit as you please. Thank you, your course was excellent. I did a lot of work using the medicine book (open next to Macleods) immediately after the course in February and over the last week I used it as an OSCE refresher.

OSCE 14 stations, 13 x 10mins (some were less than 10mins) and 2 x 5mins Take a BP. The examiner measured her BP on her other arm at the same time using an electronic cuff. (5 mins) Ophthalmoscopy: Classic, read the Andy Levy eye balls (5 mins) CVS exam: Mitral regurgitation I hope. Straight forward. Neuro: upper limb from a chap with a dystonia. Nice signs, nice examiner, and I wish Id known the entire diagnosis but I dont think it mattered. Palliative Care & Oncology/Communication: Talk to the daughter of a mother with cancer about DNAR. Discuss that her mothers cancer had spread to her brain. The actor asked me about managing pain and how her mother would die. There was a lot of information to read and take in on the information sheet at the beginning and quite a lot to get through in the time. Rheumatology: Examine hands. The patient had obvious RA. The examiner asked me where else I would examine (he wanted neck, ankles and feet) and what rheumatoid nodules were, including their usual texture! Other people got asked about side effects of DMARDs. I had practiced hands a lot so I loved this one! Communication & Disability: Explain to a blind woman how to do an MSU and lead her to the bathroom and back. I had time left over in this station which felt awkward. Discharge summary: Write a discharge summary onto a standard proforma from a set of patient notes. I did not have enough time, which was annoying because it was fairly straightforward. 6

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Student Reports on Finals 2010

Prescribing: Prescribe for acute asthma. Prescribing errors: Look at a drug chart and write down the errors. ENT: Part 1) Examine a patient. I screened hearing, did Rinnes and Webers and examined the ears. Struggled with this one because Rinnes and Webers didnt seem to match up and I failed to notice a scar! Part 2) Look at a picture of an ear drum and answer questions about it. I went for acute otitis media although it wasnt the best example Ive seen so I was probably wrong I didnt like this station: I would advise practising more with the otoscope and getting someone to fake Rinnes and Webers signs for you so can cope under pressure. Blood taking: Take blood from a nurse using the fake arm. Decide which blood bottles are needed based on a history and fill in the blood form. Straight forward but again, I was pushed for time. Portfolio review: Talk about our clerking portfolios. They did expect us to remember patients, and they pulled the cases at random out of the folder for some people. Considering I had seen these patients up to 6 months before (and hadnt looked at them since) I was pleased I could remember some relevant details. I would advise putting a sticky tab on 5 or so cases that you would be happy to talk about and hope the examiner uses those. GP: The information given was: You are a GP, your practice nurse has seen this patient who has a persistent cough. CVS and RS exam normal. A test result showing peak flow values before and after salbutamol, with an obvious improvement following salbutamol. I took a history. The cough was no better and I found out that it appeared to be related to her work as a hairdresser. Her brother had asthma. I prescribed Salbutamol and asked her to do daily peak flow measurements and then come and see me again. The OSCE was the fairest exam. All the stations tested things that are reasonable requirements for F1s. It went very quickly and I would say that if you look at what generally comes up, practise your exams and do some role playing with friends you will be absolutely fine. The examiners were neutral and professional in their manner towards me. DOSCE Format: Rolling slides in a lecture theatre for just under 2 hours, with questions about each slide, of varying depth. Slides showed surgical and medical signs, dermatology, ophthalmology, videos of patients, ECGs etc. As you can tell, a mixed bag! I left this feeling ok, but then when I spoke to others we had put a lot of different answers. I looked things up afterwards (always a bad thing to do) and had made quite a few mistakes so now Im less certain about it. LONG CASE This was the exam I was most nervous about. 1 hour: take a history and do a complete examination. Present the case afterwards. My patient had an atypical pneumonia and it was fine. My advice would be to practice presenting. Its the part that people are generally weakest at. But if you can track down a doctor on the ward

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Student Reports on Finals 2010 when youre practising for the long case, and present to them youll get better and probably learn a lot more about the management of that particular case too. EMQs 2 x 2 hour papers These were easier than I thought they would be but they were wide ranging. You would be unwise to ignore a speciality completely, on the basis of already having been examined it in fourth year for example.

Student report Bristol OSCE: Examine the ears but first look at a picture and answer some questions (I have no idea what it was!!) Examine the hands-psoriatic arthritis. The lady had psoriasis behind her ears. The examiner asked lots of questions throughout but was nice. Examine the cardiovascular system-think it was aortic regurg Tell a woman that her mother was about to die and you wanted to place a do not resuscitate order Look in ping pong ball eyes Take a blood pressure the examiner took her own blood pressure at the same time with an electric blood pressure monitor Take blood for a digoxin level label them Take an asthma history the trick was to find out that she was a hairdresser and they had changed products recently Do a PR on a model and write down your findings there was a polyp-I couldn't remember how to record it properly Explain to a blind man that he has a UTI and needs to do a mid stream urine sample and then lead him down the hall The clerking portfolio station was fine. They were really nice. Make sure you prepare a case to talk about and big up the station, they seem to love that. Some of the examiners were quite stony faced and some of them were really nice. Generally the consultants were a lot nicer than the younger examiners. I enjoyed the revision course, thank you!

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Student Reports on Finals 2010 Student report Dear Dr Clarke, I'm usually not the sort to go over exams after they've happened but as I have a number of friends in the year below I made an effort this year! It was actually surprisingly cathartic. Below is a list of what came up on the OSCE OSCE: Rheumatology - RA hand exam Neuro - upper limb - Parkinsons CVS - Examine: Mitral regurgitation ENT - Examine hearing

Partially sighted - Explain MSU, guide person to loo, explain investigations and management

Palliative Care - Breaking bad news - mother's cancer spread to brain - DNAR + Palliative options GP History - "Conduct a full consultation" - someone who's had CXR + spirometry which showed a reversible pattern of airway obstruction - discuss findings and suggest treatment PR Venepuncture + relevant tests Digoxin toxicity Clerking Portfolio Discharge summary Prescribing - Asthmatic Drug Chart Critique Ping pong Eyes and BP My long case was a lovely chap with heart failure and COPD admitted for worsening shortness of breath - afterwards they asked me how I would manage him had he just arrived in A&E and what I thought the underlying pathogenesis for his condition was. I'm afraid there were too many questions in the written to remember them all but they were a similar lay out to most EMQs and focused mainly on medicine and surgery plus a few on specialties - we had two two hour papers of 26 themes with 5 stems each. Hope this helps - I really enjoyed your course - not sure how you managed to cover so much in two days but it was brilliant!

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Student Reports on Finals 2010

Student report Hi, Firstly thanks so much for your course. It was very useful, gave me much confidence going in to the clinical exams and was enjoyable. Personally I found the surgery day the most beneficial even though generally I find it less conceptually difficult than medicine because the course material answered all those questions you always wondered about but could never find in books. The neck examination section was worth spending time on as it is something that comes up in exams but little teaching is given on it. The only other thing I would have enjoyed was a little teaching on liver failure, rather than just the post-course notes as I generally find that the trickiest part of gastroenterology. Long Case Done in the RUH Bath. The examiners were great, they had "gone to the right course". Oddly, it gave me confidence to know that one of my examiners was a paediatrician and that they were not specialists in the field - I had presumed that we would be examined on a cardiology case by a cardiologist etc, but I think the examiners are distributed randomly. As they walked down to the Gastroenterology ward with me they told me that they appreciate that we are nervous, but advised me just to clerk the patient as you have been doing every day and you'll be fine - which did help with the fear! My case was a young man with a 6 wk history of obstructive jaundice (but no gallstones visualised on investigations), including episodes of pancreatitis and ascending cholangitis within the previous weeks. He had presented on this occasion with episodes of melaena (due to bleeding from a previous ERCP). His diagnosis was primary sclerosing cholangitis. So quite a complicated story, but a great historian so was fine. They asked me to present my findings and then asked me questions on what I would expect to be the differences, in terms of examination findings, between acute and chronic liver failure. They asked me if I was an F1 in MAU how would I manage this man with a GI bleed and what investigations I would request. Written (EMQ only) Papers were quite 'specialities heavy' - with a couple of questions on dermatology, paeds (calculating fluids and congenital heart lesions) and obs & gynae, anaesthetics - pre-op assessment. Dermatology questions were not that mainstream - i.e. answers included chondrodermatitis nodularis helices and lichen planus etc but less about acne/eczema/psoriasis. There were some microbiology questions too - Lyme disease came up, as did Weil's disease twice! Hardly any questions on surgery. Medicine included a question on myocarditis. Some questions were in the form of, pt has x, suggest 5 appropriate investigations to answer next 5 questions. DOSCE Included: Psyc video answering true/false questions about an elderly lady with features in keeping with dementia/ pseudo dementia of depression. Video of man with myotonic dystrophy shaking hands with examiner. Video of man describing a seizure - asked to suggest what type ? Jacksonian ECGs including AF, mobitz 2, VF, VT

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Student Reports on Finals 2010 Ward round video of prof blazeby with patient post oesophagectomy with many drains etc & writing down wr notes - suggest write in things like date, sign, bleep etc before when finish other questions early as pushed for time Again more dermatology - video of lady with plaque psoriasis but described recent episode of guttate psoriasis Ophthalmology - video of man describing reduction in visual acuity in one eye, floaters over months and pupil looked dilated? open angle glaucoma. Other pictures - one was retinal detachment and asked for appropriate treatment Medical signs - some neuro palsies etc, nails - though terry's nails but apparently it was henna growing out! Surgical signs - shortened externally rotated leg, video of Buergers test - asked to name it and describe the important stages of the test and the interpretation Many medical & surgical signs but can remember no more!

OSCE Hand examination - lady with Rheumatoid arthritis - many features to comment on, also bilateral Dupuytrens contracture - with scar indicative of previous release surgery. He asked me to summarise - I used your booklet answer! - symmetrical inflammatory polyarthritis affecting the small joints of the hand. After examination was asked for diagnosis and differentials - ie RA, psoriatic, OA with inflam component. Had nodules on DIP and PIP - I said that they could be Heberdens/ Bouchard's or RA nodules. He asked which was more likely, I said given other findings of ulnar deviation/MCPJ subluxation RA more likely - he seemed to agree. Asked if evidence of active synovitis - I said in favour increased temp, against no pain or bogginess overall no! He then said why do you think that is -- he wanted that she's currently well medicated. He asked me to name some rxs - I gave him the list from your handbook. He then asked me what things I would follow up as she was on methotrexate - i.e. FBC, LFT, & poss. lung function. Venesection - take bloods for a lady who needed digoxin levels. Had to know what tubes to use. Took blood from the clinical fellow wearing pad on arm. Portfolio review - they chose cases at random to talk about as well as generally what I had learnt from the process. Breaking bad news to an oncology specialist nurse pretending to be a lady whose mother had just had a fall. Had to explain that her mother's ca had spread to her brain, that she was dying and that the team did not think it appropriate to resuscitate her mother if her heart stopped. Had to explain that DNAR was a specific situation and that we would continue to keep her mother comfortable and treat her otherwise. Looking at the table tennis retina and blood pressure - had to take reading whilst simultaneous reading was done in other arm to assess accuracy.

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Student Reports on Finals 2010 Disability - explain doing an MSU to a visually impaired man. Then had to guide him along corridor to bathroom. Checked allergies etc before starting anti-biotics and then checked what form he needed information in - he said his wife could read him instructions. GP station - this was not entirely clear what they wanted of you. Had actress and set of results suggestive of new asthma diagnosis - she had already been to asthma nurse . I started by taking history. She had hidden agenda that she was a hairdresser and that they had recently brought in different hair dyes. Started her on salbutamol, and asked her to make pefr diary and note breathing when in work and using dyes etc and asked if she could avoid working with them. Finished a little early - examiner suggested I asked any more qs - I then started explaining what asthma was - I think examiner continued ticking for this bit! Neuro upper arm - distal wasting & weakness, peripheral neuropathy in glove distribution all modalities (Charcot Marie tooth)?? CVS exam - AF and aortic stenosis I think. Asked to suggest how you could distinguish mitral regurg from aortic stenosis - echo. I said there was evidence of early clubbing. He said, though this man had aortic stenosis, what could theoretically tie together clubbing and a murmur in this man - i.e. congenital heart disease. Surgery - explain PR and perform on model, then record findings as you would in notes. Apparently some people found a polyp but I only found a smooth prostate! ENT - diagnose and treatment of a condition in a picture, then examine ears and rinnes/ webers. Man had a sensorineural hearing loss in one ear. Asked to suggest possible causes. There were a couple more but currently can't remember them, sorry! Thanks for all your help

Student report Dear Dr Clarke Osce finished yesterday for Bristol and I can list the stations below. I have previously sent through my long case details and I will try and remember anything I can from the DOSCE also. The format this year in Bristol changed for the writtens and DOSCE and the only advice I could give fellow students is that a lot of specialities came up in both the medical and surgical papers for the first time - so the 4th years sitting it next year need to revise all of there subjects from 3rd year onwards. The DOSCE format at Bristol used to be all about obscure blood films of pappenheimer and Dohle bodies but this year there were a lot of videos of patients and then questions about their diagnosis and management. I will list what I can remember:

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Student Reports on Finals 2010 1) 4 ECG's of VT,VT, AF, 1 and 2nd degree heart block and one question on how to manage 2nd degree heart block 2) A man's leg held in a fixed flexion deformity and cause 3) A woman describing loss of sensation to the left side of the face and asking for the cranial nerve that supplied it 4) A woman with Peutz-jegher black deposits on her lip and a question asking what it is and what is a complication 5) A man describing absence and tonic clonic seizures 6) A penis with balanitis 7) A woman with Chvostek's sign 8) An AV fistula on an arm with a bruit being heard. Asked what it was and two complications (thank you so much for this and Steal Syndrome...) 9) A consultant carrying out a ward round and you being asked to write the details down like an F1 10) A man with an abducens nerve palsy 11) A man with a CN III palsy 12) A man with Acute Angular Closure Glaucoma and management questions 13) A woman who had had a lumpectomy with wide local excision and asked what she had had and why and follow-up management for this 14) A man with a CN XII palsy and asked to which side it leant 15) CXR - two pneumothoraxes, a pneumoperitoneum, a consolidation 16) A Colles fracture 17) Pepper pot skull in myeloma 18) Atopic eczema in a child 19) Contact allergic eczema in a hairdresser 20) Plaque psoriasis 21) Bullous pemphigoid 22) Proliferative diabetic retinopathy 23) A blood film with a patient that had CLL and some management questions 24) A blood result of thrombocytopenia and some causes 25) A woman with a lower motor neuron CN VII palsy

That's about all I can remember for the DOSCE. As for the OSCE - stations below.

1) A discharge summary and discharge letter to write back to a GP after an admission of their patient. Tip is to flick to the back of the notes and they have a summary of management there 2 A prescription correction station where one has to highlight the doses and incorrect format of a patient's prescription chart 3) To write a prescription for the acute management of asthma 4) To counsel a woman who's mother was terminal and try and get her to agree to a DNAR 5) A portfolio station reviewing all the clerkings you had undertaken that year 6) A set of false eyes with numbers in the back of them for you to record and write down 7) Taking a blood pressure 8) Doing a PR examination on a bust and asked to write it up as a formal document with the pedunculated polyp described just inside the anal canal 9) Taking blood from a prosthetic arm for a patient's digoxin levels. Knowing which blood bottles to use (U&E, K and Digoxin level) and then writing it up on the blood film 10) Talking to a visually impaired patient about doing an MSU and then walking her to the loo to demonstrate you could do this 13

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Student Reports on Finals 2010 11) A gals examination and knee examination on a patient who had had bursitis removed from both knees. Asked what this could be caused by and eventually got around to psoriatic arthritis even though there were no psoriatic signs. Asked what the specific management was for psoriatic management of the knee other than drain effusion 12) An upper limb neuro on a patient with goodness knows what disease. Mixed upper and lower motor neurone signs that wasn't motor neurone but asked to look at the patient's nails which were all stained white. None of us had a clue what this was but I will email Prof Levy to try and ask as the consultant said he was not allowed to tell us 13) A woman with a CABG scar and saphenous vein harvesting and also an S1 metallic valve sound consistent with a mitral valve replacement. Also a lobectomy scar and in AF with a BP of 152 / 92 mmHg. Asked what valve she had had replaced and what the long saphenous vein harvesting was for 14) An ear exam on a patient with a conductive hearing loss. Asked for causes and then a picture with what looked like an ear effusion (it had bubbles in it) and asked questions about what this was, what causes it and management. Apparently this question was also given last year 15) Woman with a cough for 3 months and a positive reversal test with salbutamol so asked to counsel her on diagnosis and management

Student report Dear Dr Clarke, Heres what happened Long case This was our first exam 60 minutes to take a history and perform a full examination of a patient on the ward, then 10 minutes to present and answer questions. My patient was a 90 year old lady who was walking home one evening when she couldnt move for a few minutes but was fully conscious with apparently no other symptoms, then she managed to carry on walking, got home and called the ambulance and didnt know what had happened or why she was still in hospital 3 weeks later. I had no idea what was wrong with her but I went through all the differentials I could think of (e.g. TIA) to show the examiners I was thinking and tried to exclude anything serious by doing a thorough history and examination. When presenting I admitted that I wasnt sure what was going on but tried to show that I was thinking, being safe and not missing anything important. Afterwards they told me shed been complaining of severe back pain and had found that the blood pressure in her right arm was higher than in her left. They asked me what I thought and if I would be concerned about that so I said yes and that it could be aortic dissection - they seemed pleased with that so I hope it was right! So even though I missed a few things out (such as the Babinski reflex), ran out of time and didnt really know what was going on, I still managed to pass! My examiners were really nice and they want pass you, even though I was worrying about the small things afterwards, I dont think they would fail you for small things. The most important advice I can give to other students is to stay calm, be confident and just treat it as another clerking like all the other ones youve been doing the whole year.

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Student Reports on Finals 2010 DOSCE (data-interpretation osce) I found this exam quite hard. It consisted of various pictures and videos which we had to interpret and in some cases, suggest possible treatments. Heres what I can remember: 1. ECGs this question was fair, with marks available for describing what you see and working out the rate etc. We had STEMI, AF, atrial flutter, VT and VF. 2. Dermatology A picture of a man with a rash over both of his legs - I thought it looked a bit like meningitis but it cant have been because hed had it for a few weekscant remember what I put in the end. A picture of some lipsI has no idea what this was but apparently it was telangiectasia A picture of some hands covered in these little skin-coloured papulesI had no idea what this was! A picture of some nails with what looked like henna on them which had half grown out. We were asked what it was I put henna but also beaus lines because I henna isnt a pathological process! We were also asked how long this person had been unwell for I took a guess at 3 weeks.

3. Haematology there was a blood film of iron deficiency anaemia , blood results of a young woman which I think was autoimmune haemolytic anaemia. 4. A picture of a mans torsoafter studying it for some moments, the only abnormality I could see was that his left shoulder looked a bit square so I put anterior shoulder dislocation. Afterwards however I found out that other people had put gynaecomastia! 5. A video of Buergers test had to say what the test was and what is was for and also describe the leg there was a toe amputation and some skin changes. 6. A video of pitting oedema asked what was being demonstrated and some causes 7. A video of a girl tapping the side of her face to demonstrate spasms we were asked what this was called and what it was caused by Chvosteks sign caused by hypocalcaemia 8. A video of a man talking about recurrent episodes of syncope we were asked the likely diagnosis and how we would investigate it. I put Stoke-Adams attacks and 24hr ECG but other people thought it was vasovagal. 9. A video of a man describing some sort of visual loss he mentioned reduced acuity and black spots but only in 1 eye which I found confusingwasnt sure what this was. 10. A video of a consultation with a psychiatrist and a lady who was there with her mother who I think had dementia we were asked what symptoms/signs (from a

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Student Reports on Finals 2010 list) she was displaying and to choose some important things which we should ask in the history to help with the diagnosis. 11. A video of a man with a 3rd nerve palsy. 12. A video of a man shaking hands and not being able to let go, and then his thumb was tapped with a tendon hammer (Im not sure what this was), I put myotonic dystrophy for the diagnosis. 13. This confused me. It was a video of someone was holding a Doppler over the back of a leg, then squeezing the leg below it (or above it? I cant remember!), which would stop the sound transmitted from the Doppler. We were asked what was being demonstrated I found this confusing as I thought Dopplers were used for arteries and yet it seemed like the person had venous incompetence...as you can tell, I still dont really know what was going on here, Im not sure if Ive even related this correctly so its probably not much help! There was also a brown pigmented area of the calf which we were asked about so I put haemosiderin staining.

OSCE I thought this exam was quite fair, consisting of nine 10 minute station and four 5 minutes ones. 1. Portfolio review two examiners asked me a few general questions about the portfolio and then asked me to choose one case in particular to talk about I hadnt marked out any specific cases so just had think of one on the spot, then I couldnt find it despite my nice neat contents page so after a few moments they asked me just to talk about what I could remember from it. Fortunately I managed to come up with something and answer their questions. I would definitely recommend keeping a couple of cases in mind to talk about if you can but I also heard that sometimes the examiners choose the case they want you to talk about. 2. Disability - we had to explain to a lady with visual impairment who (in the scenario) had come into A&E how to do an MSU, then take her to the toilet (in reality out of the room, up the hallway and back) and then finish off by explaining that the result was positive, making sure she understands etc. 3. Ophthalmology 5 minutes to read the letters in the ping-pong eyeball using an ophthalmoscope. This was easier than expected as there were only letters and not words as there usually are. 4. Blood pressure 5 minutes to take the examiners blood pressure as accurately as possible. 5. Venepuncture from a patient who needed to have his digoxin levels checked. We had to choose what tests we wanted, take blood from a fake arm (which was much easier than the fake arm they let you practise on), label the bottles and bag and put the bottles in the bag etc. You would lose marks

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Student Reports on Finals 2010 for doing unnecessary blood tests so you couldnt just do everything. Try not to forget simple things (like I did!) such as labelling the bottles! 6. Digital rectal examination on a model make sure you know the procedure and can describe what you find. I dont think I was doing very well at first but the examiner was really nice and prompted me. There was a small polyp and a prostate which may have been enlarged but it was smooth. Then you had to write your findings on a continuation sheet as if you would write it in the notes, making sure you signed and dated it etc. 7. Drug chart review identify the errors on a drug chart. Use the bristolmedicalpro website to practise. 8. Prescribing had to prescribe for an asthma attack, theres a BNF but you only have 5 minutes so its best to know it already and then you can use it to check. Revise prescribing for the main emergencies. 9. Discharge summary this would have been fine if it wasnt that we only had 10 minutes. The patient notes they gave us to look through were pretty thin but I still ran out of time. 10. Palliative care/oncology a woman has just arrived from Scotland after hearing that her mother (who has metastatic cancer) has been found unconscious and is now in hospital. A CT scan has shown several brain mets and a bleed into one of them its likely that shell die in this admission. You have to tell her that its unlikely her mother will recover and discuss what to do from here including a DNAR. This is all about communication and breaking bad news which weve been practising since first year so it should be ok, just need keep practising and then combine with some knowledge from palliative care & oncology. 11. GALS screen and answer questions the patient had psoriatic arthritis, examiner wanted to know differentials and treatments (for the arthritis not psoriasis, so make sure you know it properly!) 12. Upper limb neuro examination a man in a wheel chair with LMN signs, Im not sure what the diagnosis was, unfortunately I couldnt think of anything in the few seconds I had left! 13. Cardiovascular examination I could hear a prosthetic valve ticking away and the patient had a midline scar but no leg harvesting scars your cardiology teaching helped me out with this! I was trying to remember which valve goes thud-click and which is click-thud I said it was mitral in the end but apparently shed had aortic and mitral replacements. EMQs Two 2 hour EMQ papers on medicine, surgery and specialties which were not divided into these categories so it was hard to tell how much of each there was, I think they jus want a broad range of knowledge. I found these generally ok and actually quite enjoyed doing them! Theyre also quite fair - the best answer gets full marks but less good answers also carry some marks, and no negative marking!

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Student Reports on Finals 2010 So despite all my worries beforehand and finding some parts of the exams quite difficult, I managed to pass! Its very nerve-racking especially when youve been working towards these exams for so long but youve just got to hang in there and do your best! Thank you so much Dr Clarke for your revision courses I really enjoyed attending them and found them really useful, the handbooks definitely helped with structuring my revision and included some things I would probably not have bothered revising very well had they not been in there. Your website is great as well!

Student report Dear Dr Clarke Firstly I would like to thank you for your revision course held at Bristol. I attended both days - it was really helpful for our clinical exams, giving us a broad overview of the most important aspects of medicine and surgery. I found your mnemonics particularly helpful. Long Case I was really lucky to be in the Swindon academy for this exam (the academy with the highest pass rate). The examiners were all very friendly and fair and the cases they picked were all general medical patients that you would typically find in a DGH. My examiners were a consultant gastroenterologist and a consultant orthopaedic surgeon. My patient was a fully independent 66yr-old man with an exacerbation of COPD and a probable UTI. The history was a little unusual so it took me a little while to figure out what was going on but the examination was straightforward. Leaving myself a few minutes to review the obs chart and work out an intelligent-sounding summary was a wise choice. As expected, they quizzed me on acute management. I came out of the exam thinking it had gone reasonably ok, but like a lot of other students I began to doubt my own performance as the days went by. The best thing to do is not to let it interfere with revision for the writtens! EMQ A fair selection of clinically-based questions (including specialities) across 2 papers, just generally very poorly written! Quite time pressured; there were 26 available options for every question. For many of the questions it was easy to think there was more than one appropriate answer. Luckily, the answers are graded to award you full marks if you picked the most appropriate answer and partial marks if you picked an answer that was also logical. DOSCE More difficult than I expected it to be. Included: ECGs Dermatology Blood films X-rays (CXR/MS) Video on psychiatry Ophthalmology Surgical signs - pictures and videos Medical signs - pictures and videos Ward round note taking

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Student Reports on Finals 2010 Generally, important to watch the timer because there is danger of missing the first part of the video clip for the next question (and they aren't repeated, despite there being enough time to rationally do so)! Apart from the ward round note taking, probably advisable to write your answers at the end of the video clips because some videos contain other images such as scans and things that can give you clues and you might miss these if you're busy looking down and writing on your answer sheet. OSCE Prescribing for acute asthma Drug chart errors Upper Limb Neuro - MS CVS examination - AS Ping-pong eyes BP Portfolio review Discharge summary GP history - adult onset asthma Disability - explain MSU to a visually impaired patient and guide them to the toilet Breaking bad news - explain to patient's daughter that her mother (with metastatic lung ca) is DNACPR Ear examination and picture with questions Venepuncture - renal failure and digoxin levels Hand examination - RA and discussion of DMARDs PR exam - examiner asked you some questions on how you would do it, then you did it on the model, after which you had to write it in the patient's notes and give your paper to the examiner to mark

Hope this helps :)

Student report Dear Dr Clarke, Many thanks for all of your help at the course - it was incredibly helpful, particularly for the OSCE. Here is my interpretation of Bristol finals 2010: 1. Long case: unbelievably nerve-wracking, and everyone seems to have had very different experiences. Mine was quite a tricky case with a difficult historian who had been in hospital for several months. I did my best with the history and just finished the examination in time. I was asked rather bizarre questions regarding his drug chart rather than the expected questions regarding differentials and management. 2. EMQ papers: really exhausting 4 hours in one day. Some of the questions were fair, others were more obscure and I left feeling that much of it I would never have known, despite more hours/days if revision. Also some questions were of an unfamiliar format for Bristol with a 'choose the best of 5 answers' style. 3. DOSCE: a nightmare! Really different from all the mocks I had done and by the sounds of it from previous years. Less of the traditional and predictable

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Student Reports on Finals 2010 haematology/ ophthalmology questions and much more weird and wonderful medical and surgical signs. Again really difficult to revise for... 4. OSCE: 15 stations in 2 hours 20 mins with no rests! Exhausting, but overall a fair exam. These are the stations as far as I can remember: 1. Palliative care/oncology: discussing a DNAR decision with the daughter of a terminally ill patient 2. ENT: examination and presentation; picture of an ear with questions - I thought it was glue ear 3. Disability: taking a blind woman to the toilet and explaining how to do an MSU specimen 4. Prescribing: acute asthma 5. Prescribing: marking the errors 6. Surgery: Digital rectal examination 7. Cardiovascular examination on a man with loud aortic stenosis 8. Neuro examination on a man who I think had a c-spine/brachial plexus lower motor neurone lesion 9. Writing a discharge summary 10. BP measurement on the examiner 11. Ophthalmology: reading letters in back of a fake eye 12. Clerking portfolio station 13. GP: discussion with a patient with newly diagnosed asthma 14. Rheumatology: hand examination of a man with RA 15. Venepuncture and appropriate tests for a patient on digoxin with renal failure. Thanks again, Student report Hello Doctor Clarke! First I'd like to say a great big thank you for all your help and advice. Initially I thought your course was quite expensive, but I can now honestly say it was well worth it! You managed to break things down so that things that had been confusing me for ages became suddenly clearer! I particularly found the diagrams and flow charts made things clear and your handouts were really easy to revise from. Feedback about Bristol finals: (I'm sure you're already aware, but I understand that Bristol finals will be in December for this coming year of students). OSLER: This was the exam I was most terrified about, as you feel like almost anything could happen. However, most of the patients chosen were fair and in those cases that were more complicated, the examiners clearly appreciated this. The patient I was taken to see was an elderly lady admitted with pneumonia about 3 weeks ago, also under investigation by respiratory physicians at the hospital for lung fibrosis but she wasn't too sure about these details. She was also quite hard of hearing which made communication a little difficult. She also mentioned that she had heard 'noises' in her head on two occasions over the last few months. I didn't have enough time to go into this in detail as her respiratory history was quite complicated.

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Student Reports on Finals 2010 I worried later that I had missed her describing a psychotic episode, and noticed she was taking a typical antipsychotic which I mentioned to the examiners. She was taking long term steroids, which may have been responsible for this, and I kicked myself for not realising this in the exam! EMQs: Not what we were expecting but OK overall. Many of them gave a clinical history then a list of investigations/treatments, asked you 2 chose the 5 most appropriate. I remember laughing that pseudopseudohypoparathyroid came up there somewhere! DOSCE: This was a very fast paced exam which I don't think you could ever be fully prepared for! We were given sweets though! Also noticed (afterwards) that this exam was very similar to one a couple of years before. Most of it was fair, but some funny ones. Everyone thought it was quite difficult. Don't worry too much though as you can fail about 7 stations between this and the OSCE and still pass. Stations I can remember: 1. ECGs - 2 x 12 leads - I think they were STEMI and axis deviation, they had quite a few things on them. Then there were 4 rhythm strips which were easier, AF, VF, VT and Wencebach I think. 2. Dermatology - Guttate psoriasis, BCC/SCC? Purpuric rash. Impetigo 3. Ophthalmology - a man describing some sort of visual disturbance, we all had different answers. I wrote ARMD but I have no idea what the answer was! Think there was an eye with a blue patch (scleromalacia?) and retinal detachment also. 4. Haematology - Blood film of Iron deficiency anaemia. Shown an Xray of pepper pot skull, had to give diagnosis (Multiple Myeloma) and name 5 appropriate investigations 5. Radiology - Chest X-rays, including pneumoperitoneum, can't remember the rest! Colles # 6. Medicine - lots of video's picture: parotid tumour, young-ish man complaining of collapses (I thought it was cardiac), cranial nerve lesions (eyes), RAPD eye (which eye is affected) 7. Surgery - again lots of things - rectus divarification, picture of a leg shortened and rotated (#NOF), paraphimosis, video of someone carrying out Burger's test, man's chest & arm that looked like shoulder dislocation/brachial plexus injury but about half thought he had gynaecomastia, so who knows! 8. Ward round note taking- very fast, but you have a few mins to not down time, date, place, consultant etc before you start. Sign, give your bleep no and name. OSCE: Not a bad exam, quite fair. Here's the stations I can remember: 1. Upper limb neuro. I was confused as examiner didn't want to hear about my differential, only where in the brain I thought the problem was. I said upper motor neuron, and he kept pushing for something else, should have said cerebellum. Still passed this station though! 2. CVS exam - man with really obvious murmur and all the signs of mitral regurg. I think the examiner was impressed that I picked them all up, starting at his pulse! Asked about the causes and some things about other murmurs. 3. Taking blood from a fake arm strapped to a nurse. Had to label bottles and ask for appropriate tests for the given patient scenario. 4. Disability - a man who was visually impaired and had urinary symptoms. Had to take an MSU (explain how to do this) and start on Trimethoprim as his symptoms were quite typical. Then had to lead him to an imaginary toilet which completely confused me. 21

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Student Reports on Finals 2010 5. Script writing - acute asthma attack. Most people gave some drugs immediately, some PRN and some regular 6. Script error spotting - look for the obvious name, dob etc then look up doses and things in the BNF provided. Practice the Levy ones online. 7. Discharge summary - really confusing set of notes, not entirely sure what had happened. Again make sure to get the basics down first. 8. Hand examination - gouty tophi, asked about diagnosis, treatment and problems (e.g. with acute gout and allopurinol) 9. PR examination model. 'Patient' needs to be in left lateral position - explain to and reassure patient. Had to record findings in notes using diagram and description (e.g. any visible lesions, blood/mucous on glove). Record site of lesion - was polypoid. 10. Breaking bad news - discussion with only daughter about mother who's lung cancer has metastasised. Explain she is dying and answer any questions Daughter was worried as her dad had not been given enough pain relief whilst he was dying in hospital. 11. Ophthalmology Levy eyes & BP taking. Think that's everything. Just remember to keep calm and carry on and it'll be over before you know it!

Student report Finals in Bristol Im a newly qualified F1 having just graduated from Bristol Medical School. I wanted to email to tell you about finals in Bristol as reading about what had previously happened in Bristol on your website really helped me prepare for my exams. What I learnt on your course has also been really useful for everyday life working as an F1. Id like to say thank you for all the hard work you put into your revision course. I went to your course in London at the beginning of the year and it really helped me gain some perspective on what I needed to learn. I definitely feel it was money well spent and have recommended it to my friends in the year below. Overall I found the exams reasonably fair, there were only a few things I had absolutely no idea about and it seemed like the majority of people I spoke to felt the same! In Bristol we have four exams. The long case, written exam papers, DOSCE and OSCE. The long case Take a full history and carry out a full examination on a patient in an hour, then present and answer questions for a further ten minutes. This was the first year they had brought in mock long cases, where we had been watched on two previous occasions during the year doing exactly what this exam tests, whilst being watched by a consultant who would give us feedback on how to improve. I had a lady who was waiting to go home after being in hospital for 2 weeks with cellulitis. She had also had a craniopharyngioma when she was 9 years old. I ended up with the Professor who sets the exam and a General Surgeon watching me. I took a history and examined the patient but ran out of time as I was about to examine the patients cranial nerves. 22

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Student Reports on Finals 2010 At the end I mainly got questioned about how I would get the patient to lose weight (she was quite overweight and Id had lots of trouble getting her to move on the bed!). I started off with conservative measures but the kept pushing me until I said gastric band surgery. It definitely wasnt my best clerking and I said a few stupid things under the pressure but I passed this exam so luckily I didnt have to do a second long case. This is the only exam they let you retake before the final results come out. Written exam Two 2 hour papers on the same day, one in the morning and one in the afternoon. They had changed the format of the exam this year so that there were no longer negatively marked MCQs. Instead the whole exam was EMQs. The majority of the questions were fair however there were more questions on clinical specialties than I expected- Id been told to not bother revising obs and gynae and paeds as they never come up in finals! Luckily the speciality questions seemed to focus on important basics. Some of the questions were very different to those in practice EMQ books. For instance giving a clinical scenario and asking what you as an F1 considered to be the most important pre-op investigations or asking the five things you would do to manage a moderate asthma attack from a selection of 26 options. DOSCE This exam is in a lecture theatre with numerous pictures and videos projected onto a screen and you write the answers into an answer booklet. There were a number of different sections and it goes quite fast without a break for 2 hours. I think the important thing about this exam was to try not to waste time thinking about the areas you found difficult as you would have a new question to think about in a few minutes time. These are the sections I can remember;

ECGs- two 12 lead ECGs asking questions about rate, axis and the likely cause and 5 rhythm strips- VF, VT and mobitz type 2 are the ones I can remember. Psychiatry- a weird video was played with an old lady and her daughter having a consultation with a doctor there were then true/false questions to answer. Radiology- several x-rays asking about the obvious abnormality and then questions about investigations or management. All I can remember is air under the diaphragm and bronchial carcinoma. I think there was spine x-ray but I have no idea what was going on in it and a thumb fracture. Medical signs- mainly videos of signs of people describing signs with questions asking what is this then the likely cause or management. From what I can remember there were a lots of cranial nerve palsies. Surgical signs- similar to the medical signs section. There was a dislocated shoulder, Buergers test was shown and venous incompetence illustrated by a doppler. Ophthalmology- a video of a patient describing what I think was ARMD, a picture of retinal detachment and scleromalacia which I would not have known about had I not read last years finals report on your website! Ward round note taking- a video of a ward round where you have to write down everything as you would as an F1. I found it was reasonably fast and I didnt seem to have enough space to write everything down. Haematology- Iron deficiency anaemia- a picture of a blood film and koilonychias and some blood test results to interpret.

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Student Reports on Finals 2010 OSCE These either take place in the BRI or Southmead in the clinic areas. This year there were 15 stations, 13 were 10 minutes long and 2 were 5 minutes long. The stations were;

Palliative care/ oncology station- breaking the news to a patients daughter that was going to die and discussing end of life care. The patient had lung cancer and had recently stopped chemotherapy, she had collapsed and when she came into hospital they discovered she had brain mets. Discharge summary- write a discharge summary from a fake set of notes for a man who came in with collapse. They used a BRI discharge form which I had not seen before and I could have done with a lot more time but I had a reasonable go of trying to put all the important facts down. The patients drug chart was filed at the back (I know a few people struggled to find it) Clerking portfolio review- a nice station. Just discuss your clerking portfolio that everyone does during the year. I ended up talking about how the portfolio benefitted me and discussing an interesting clerking and bits about the management. BP and fundoscopy- five minutes to write down all the letters in a Prof Levy eye then five minutes to take the examiners BP. GP station- I found this quite a difficult station. A 30 year old lady who was suffering with SOB. You were given the ladys peak flow readings before and after salbutamol nebuliser(shows reversible airways disease) and asked to discuss the results and management as though you were a GP. I asked about her symptoms, family hx and whether she had done anything differently recently that may have caused her symptoms then I explained what I thought it was asthma and prescribed her a salbutamol inhaler. The lady kept asking why she had developed it now which I wasnt really sure about. Apparently she was a hairdresser and the chemicals they use were causing her symptoms I still passed the station so Im guessing they were looking for a combination of things. Surgical station- PR examination. The examiner asks you a few questions about PR then get you to perform one on a model and write up your findings. Clinical skill- blood taking. Read a clinical scenario, choose the appropriate blood bottles then take blood out of a plastic vein (probably the best vein you will ever take blood out of!) Then write details on the bottles and fill in the request from. Upper limb neuro examination- my patient seemed to be completely normal on examination but reported difficulty undoing a buckle I got asked to list lots of possible differentials. Disability station- explain how to do a MSU to a blind lady then lead her to the toilet. Cardiology examination- Probably the worst one mainly because the examiner had a very odd manner. The lady had a mid line sternotomy scar with a scar down her left leg and ticking heart valve that you could hear from the end of the bed and an irregular pulse. Then asked what valve she had replaced. Probably on of the worst cardio examinations I had every done but I still passed so the marking scheme must not have been too harsh! 24

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Student Reports on Finals 2010 Rheumatology- perform a GALS screen on a lady who appeared not to have anything wrong with her. The examiner then told me that a year ago she had been very different and got the patient to tell me how she had RA and closer examination of her hands revealed some swelling. I got asked a few questions then left the room with several minutes to spare. ENT station- examines the patients hearing then look at a picture and answer some questions. I have no idea what the man had but he had quite confusing rinnes and Weber results. I think the picture was of an ear drum perforation. As expected I failed this one and I still have no idea what the man had wrong with him! Prescribing errors- spot the errors on a drug chart, exactly the same a Prof Levys practice ones he puts on his website. Prescribing- prescribe medication for a patient who was admitted with asthma

Student report Thank you so much for an incredible revision course: initially, I was slightly sceptical about the value of such courses, and chose to just attend yours, as I'd heard excellent feedback about it. In retrospect, I'm glad I made this decision: your course truly helped to consolidate the vast amount of knowledge and clinical acumen required to pass finals. The books are awesome too, I read through each just before the written and clinical exams. Thanks once again for your course, I think it helped a great deal, especially in terms of developing a systematic approach to presenting a patient.

Student report Just want to say a big THANK YOU! your courses and website resources have invaluable during my revision and I really do think that you gave me some great advice for getting through those final exams with minimal stress! For those doing finals next year I really would advise the Dr Clarke revision courses and in terms of approach to the exams would have to say most important thing is to keep calm! Worse thing would be to go in feeling anxious after a night of cramming.

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