The clinical finals in 'Medicine and Surgery' consist of three clinical examinations:

1. 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.
    
2. 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.
    
3. 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

1. Think before you speak
2. 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.
3. 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.
4. 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:

1. Chest pain ? Angina
2. Smoker
3. Diabetes mellitus
4. Hypertension?
5. Left carotid bruit and.History of amaurosis fugax.
6. Systolic murmur ? Aortic stenosis
7. Occupation
8. Alcohol excess?
9. Social

For each problem, think how an examiner may wish to pursue questioning:

1. Chest pain ? Angina:
   • Differential diagnosis
   • Features to support diagnosis of angina
   • Investigations
   • Management
2. Smoker:
   • Smoking cessation ?drugs
3. Diabetes mellitus
   • Is there evidence of microvascular disease? (eg Fundoscopy, peripheral neuropathy)
   • Oral hypoglycaemic agents / insulin
4. Hypertension?
   • How would you investigate someone with hypertension?
   • How would you treat someone with hypertension?
5. Left carotid bruit and Hx of amaurosis fugax
   • How would you investigate?
6. Systolic murmur
   • ? Aortic stenosis - ? How to investigate
7. Occupation
   • Relevance of diagnosis to driving (DVLA) regulations
8. Alcohol excess?
   • Assessment of alcohol dependence
9. Social
   • Social worker, re-housing, etc