ANIKAS FINALS GUIDE

Hi my name is Anika Kaura, I am now a foundation year doctor at Charing Cross Hospital. I
wanted to write a guide to final courses having been at Imperial and understand how confusing
it all is. Nishs guide to finals is very comprehensive so I will only cover the courses bit but if
you want any other advice email me on ak8009@ic.ac.uk.
Finals is stressful because a) it is earlier in the year for the first time ever! b) no one knows what
they are doing and how to revise c) there are billions of courses you could spend a fortune on
and d) everyone hypes up finals and stresses each other in true Imperial fashion for no real
reason!
I wasnt sure which courses to go on and which books to buy and tried to ask previous final
years for advice, I probably went on more courses than I needed to, more because I didnt know
which to pick , in retrospect on the whole I am glad I went to them. People go to courses for
different reasons- get their ass in gear for revision, tell them if they are revising in the right
way/how much more they no need to do, or actually for recapping. Thinking about why you
think you need to go to a course, and it will make the decision about which one and when to do
it easier.
I will give you my take on each of the courses, health warning: this is my personal opinion and
those of my close colleagues, everyone learns in different ways so even when one person thinks
it was rubbish a lot of other people could benefit from it.

BROMPTON PACES
Held early in the year, a single Saturday at the Brompton organized by registrars who charge about 5
pounds for the day, allocated on a first come first serve basis via email. You go around a circuit of the
different medical stations in small groups of 6. I was lucky enough to get on this. It was useful in terms of
going over exams, basic concepts and some practice of viva; but some stations were not useful as at this
point in the year we were all at different points in our learning!

DR MIRZAS AT WEST MID

An 8 week course (one evening each week) at West Mid given by Dr Mirza at West Mid. I did not know
him before the course and was not sure what to expect but I thoroughly enjoyed it! This was right up my
street he was very engaging using acronyms and unique ways to remember things getting you to
chant it during the lessons! He gives you this massive manual at the start which is very daunting but its
one sided so not actually that big. The book is very useful- it gives you the salient points, answers to
things that are typically asked in the exam and some gold star material. What I really liked was the

interactivity, it really stuck in my head weeks later especially the acronyms, and I actually used the
material for my answers in the real exam!

BARRYS SURGERY COURSE

A 10 week surgery course held at Kings. Everyone feels peer pressure in to doing this because at the end
of the day Mr Paraskeva is our head examiner. His course guide is excellent- a concise source of all the
surgical information you will need for finals- I didnt really need to use any textbook on top of this. The
downside is its really long- 10 weeks, and then having to go to kings each week and each session covers
a lot! If you are up for the interaction and brave enough to be grilled its worth it! But if you are not
really a lecture sort of person i.e. you zone out and then just read the handbook later then I am not sure
it is worth your while.

DR CLARKE COURSE
A weekend, can opt to do one Saturday Medicine and one Sunday Surgery or both. I did this later on in
the year so was much more revision of the basics. Dr Clarkes course if great, a neat little handbook that
covers the core concepts each day and again he keep things really DYNAMIC throughout the day so you
dont get bored. He really gets back to basics and why you are doing things each step of you
examination and tells you how to answer the most common questions asked in finals. If you choose to
go to this I would recommend doing this a bit earlier in the year to give you a kick start and remind you
of the basics.
A separate mention for Dr Clarkes Report- I cannot stress how invaluable these are! These are incredibly
detailed accounts of previous final years experiences of paces. Give yourself plenty of time early in the
year to read these thoroughly these will be the best thing in bracing you for the experience. Highlight
the things you dont know and look them up! Practice and rehearse the answers that previous students
gave- I know this sounds ridiculous but its the best way of articulating yourself! Explore the rest of the
website there are some really good ortho notes and cases.

FINALS PACES
A weekend at West Mid organized by juniors/SHOs/regs mainly ex-imperial and who got distinctions,
early in the year. This weekend is incredibly intense requiring 100% concentration for both days! The
focus is the viva bit and presentation. I did find it useful in getting my head around the way I needed to
prepare for finals and style of presentation, but it was quite early in the year, I think I would have
benefited from it if Id done a bit later. The handout from the weekend is really ace!- very concise and
great to review all the material in the run up to the exams.

MOCK PACES
I didnt get onto a single mock paces despite trying desperately hard, there are quite a few like Chelsea,
Ealing, central mid etc just make sure you regularly check your emails!
From what I heard from friends- they are definitely useful in practicing the set up of the exam, seeing
real cases like splenomegaly, and getting the viva experience. I just made sure I saw all the common
presentations at least a couple of times and I did well! So dont worry if you dont get one! There might
be a charing cross one if we can get enough doctors and patients!

BOOKS
CASES FOR PACES is your medicine bible- I promise you that if you know this book back to front you will
do well! Use the oxford handbook to supplement this and the bits it doesnt cover so well and more on
investigations etc. Making flash cards for the common presentations is something I found to be a useful
exercise.
Barrys guide is all you need for surgery, lecture notes and surgical talk are basically a different format
depending on whether you like prose or bullet points. The Ramachandran cases books is really ace for
cases, shorts, viva questions, and random ortho stuff that no one ever teaches you about like hallux
valgus which you actually need to know.. see my own account of finals later!
Pharm- go over Schacters notes and the Pod Medics notes like four times at least and then memorize
doses of common stuff like paracetamol, heparin for dvt treatment, salbutamol nebs etc and especially
the emergency and copd/asthma stuff well! COMMON STUFF IS COMMON!
COMMON STUFF IS COMMON! I cannot stress this enough. Dont waste time learning loads about
charcot marie tooth and friedrichs because you heard it comes up at chelsea (although I did of course
lol). Learn common stuff i.e. COPD, heart valves, Parkinson disease, alcoholic liver disease- this is the
stuff that will come so learn it to death!
PUBLIC HEALTH- go through the lectures- the content that is relevant like different types of study not all
the random graphs, and the MedEd sessions, then do some questions
QUESTIONS- do loads! Sign up to one of the websites like on examination or pas test early and keep
doing the questions there are thousands and you wont get through them all! Sign up with a friend and
share the log-in if you want. Dont wait to start to doing the question because you think you should do
some revision, just start and even if you get them wrong the explanations are a fantastic way of
learning. Also do the get ahead books, there are some other books out there as well and these are all
just extra sources!

TUTORS AND THE WARDS

Everyone obsesses about getting tutors and yes they can be helpful but at the end of the day its not
anything you cant do with some friends and some determination! I had a great medical tutor who gave
me the confidence in my ability to find signs and present, and really pushed me on the viva front! So if
you know any medics ask them early and make sure they commit some time to you, I know plenty of
people who rarely saw their tutors. I saw my surgical tutor a handful of times- it was useful when we did
have a session but this was not often. I would say that in surgery it doesnt matter so much, as long as
you make the effort on your own to find the signs on the wards like incisional hernia, inguinal hernia,
varicose veins, vascular surgery scars etc.
And once youve found a sign, be convinced by it take your time with that patient to not only
appreciate the signs, but their whole story, background and other signs that give you clues to any
diagnoses. You do not have to hear aortic stenosis 20 times! Once you have heard two or three times
you know you have it covered- so dont waste your time on the same signs and always be convinced!
Please be nice and

respect patients I know this is obvious but patients do actually get quite upset

around finals time! Leave them alone if it is clear they have been examined to death even if you really
really really want to get the sign.

DONT GET TOO STRESSED- this is the best advice ever. I relaxed most of the year and
plodded along then amped it up in the preceding few months making sure to see enough patients and
not leaving pharmacology too late! Dont get caught in the shit storm that is imperial finals stress, focus
on you, dont let others dump their stress on you either, Reynolds is a dangerous place for this! A lot
boils down to what happens on the day as you can tell from my own Dr Clarke finals report! Wishing you
the best of success, dont hesitate to email me and I recommend you read TRUST ME IM A JUNIOR
DOCTOR its pretty funny stuff and itll keep you smiling in the run up. I have included my account of my
finals for medicine and surgery just in case you cant find it via the Dr Clarke website.
Some useful websites:
http://www.askdoctorclarke.com/
http://www.revise4finals.co.uk/medicine/learn/examinepd.php
http://almostadoctor.co.uk/
http://www.surgical-tutor.org.uk/default-home.htm?principles/technique/sutures.htm~right

Dear Dr Clarke
In true fashion, here is my paces report since I benefited so much from previous years
experiences. I was on the last day in the afternoon at Chelsea, I think when you are last you just
have to stay on the ball and not go stir crazy! Just before the exam stay focused and relaxed
and dont get bogged down in the details. Paces is very much about doing a quick examination
whilst picking up the signs, and being able to talk sensibly and quickly about differentials and
the basics of management. You will practice with your friends, viva-ing each other for hours on
end, asking each other about minutiae- you dont have time for this- just make sure to talk
through about all the main presentations for each system. Most will pass, and only a few get
the gold star- this is so much about LUCK! There are a lot of clever people at Imperial and it
boils down to the day- were the signs easy to get, did the examiners ask you harder questions
and did you have time for them. Dont worry about this- just do your best on the day
obviously much easier said than done. I managed to stay calm and very confident, this helped
me tremendously. I will be publishing a guide to final year since I think I have been on every
course possible so watch out for it!
DISCLAIMER: it is helpful to read these reports to gauge what is required of you, but in a way
take with them with a pinch of salt, they are peoples perceptions of their own experiences and
are not representative, the reports are only a small proportion of people in the year who bother
to write one- so there is definite bias!

MEDICINE- CHELSEA AND WEST DAY 3 AFTERNOON

NEURO
Gift station- as finals years would say! Saw the resting tremor from the window. I knew it was
PD but did the upper limb exam first then got her to do hand movements and walked her.
Examiner was quite stony faced- asked me to present, the cause- offered idiopathic parkinsons
and listed all the Parkinson plus syndromes. How would you managed- chucked in MDT and
physio, medical- LDopa with decarboxylase inhibitor. Asked me about side effects- said
peripheral as in autonomic dysfunction and central like visual hallucinations and psychiatric that
can be treated with atypicals like clozapine. First station and a great start!
SHORTS
Lovely neurologist examining so felt a bit more at ease. Walked into one room with two
patients. Took me to a gentleman and asked me to examine his face and hands. Ridiculous
clubbing, was confused about the face- had very blood shot eyes and they were in slightly
different positions! Also showed me a skin lesion of patients left ankle- looked like an

overgrowth of normal skin. He asked me if I could put this together- had no idea! Told me to
look at the eyes again managed to blurt out proptosis- asked me for causes- got onto thyroid
eye disease- then figured it was thyroid acropachy and pretibial myxedema- boom! Do not
know how I figured that one out
Took me to room opposite, gentleman sitting in a chair- asked to examine eyes particularly
movements. Obvious ptosis of the left eye and reduced range of all movements on this side,
nystagmus of the right eye particularly looking down and in. Figured out that the left eye was a
fake eye! Asked me about the nystagmus down and in- superior oblique, and then about lateral
gaze palsy. Managed to get some anatomy in- brainstem pathology and cavernous sinus
pathology. Asked me to explain the cover test. Shorts over- and surprisingly no fundoscopy
which I was psyching myself up for! Although other people on my circuit had it.
REST STATION
Actually felt pretty chilled out at this point, having a gossip with one of the fifth years
HISTORY
Lovely old gentleman with a cane and walking boots, two female examiners. Felt a little
intimated being looked over by the two women but I held my own. Very straight forward
history, cardio- history of couple of episodes of palpitations, had a dysrythmia cant
remember now think it was a bradycardia, offered pacing but had declined, not much else in
the history and finished well before the half way bell. Turned to the examiner she said is there
anything else you want to ask- thank god I had a brainwave to ask more about some tingling in
his feet he had mentioned before- started to develop peripheral neuropathy! She asked me
about the acute management if this gentleman had presented to casualty, I went through
ABCDE and not just saying the letters but actually detailing everything I would doshout out to
him, check for any signs of breathing, head tilt chin lift, anything obstructing the airway, check
the pulse, different types of airway adjunct and then onto cardiac monitor, pharmacological
intervention for the dysrythmia. Remember in finals you cannot get away with just mentioning
something in passing and glossing over the details, every time you mention anything be able to
explain and back it up a thousand times! The content and presentation of what you say are
just as important as each other! She then went onto quiz me about peripheral neuropathy- gift
question! Talked about the common causes like alcohol and diabetes to the weird and
wonderful managed to get friedrichs in score! (had a bet with a friend that I could get
friedrichs a mention lol)

CARDIO
Ace station! On inspection heard the click and showed I was listening for it! Midline sternotomy
scar and metallic sounding second heart sound. I managed to round up my examination quickly
and presented my findings confidently. I was asked about reasons for the valve- waxed lyrical
about aortic stenosis and arotic regurg- causes, clinical findings, severity, investigations, echo
finding etc. If you offer the information before they can even ask it you look like youre on the
ball! Then asked about different types of valve- lovely question- rehearsed answer about pros
and cons of biological vs metallic! And the complications of valves- a favourite Mirza acronym
helped here- FIBAT- Failure of the heart of the valve, Infective endocarditis, Bleeding because of
anticoagulation, Anaemia as in MAHA and Thromboembolism. I felt like my hours of rehearsing
valve questions really paid off on this one!
RESP
Lovely examiner. Young gentlemen in a tracksuit, his right arm was twice the size of his left I
figured it was lymphedema, loads of track marks ?IVDU, clear that he was an inpatient! You see
before I even touched the patient I have an idea of this guys background: young guy IVDU
inpatient- which doesnt mean you should jump to conclusions but your presentation should
include all these observations! I heard a widespread polyphonic wheeze, he got very short of
breath so didnt make examine the front- yes more time for questions! Presented the case,
differential for wheeze, talked a bit about asthma. He asked me what diagnoses might you miss
in an asthmatic- offered PE, the bell went and he added pneumothorax. Interesting case!
ABDO
Very young chap, seemed perfectly well, dressed in his own clothes and very nice examiner. Got
him onto the couch and away I went. It was hard to find any pathology! I spotted the tiniest of
scars in his umbilicus but surely this was not the only sign! I thought I felt some splenomegaly- I
dont know if this was partly desperation thinking I must find a sign!- remember they can trick
you with a normal patient if they are short of cases! I presented the little scar and
?splenomegaly. He asked me differentials for the scar- offered SILS and umbilical hernia, he
then said think paediatric- again said hernia, widened the differential to bowel resection for
NEC and then eventually ramsteds pyloromyotomy- which it was- bizzare! He didnt actually
have splenomegaly which I learn at the end, but he used it as a discussion point for various
causes of splenomegaly, all about malaria different types, life cycle, hematological
malignancies, biggest killers in developing countries. I enjoyed the discussion as I was well
versed in splenomegaly but was thrown by the fact that the only sign was this tiny umbilical
scar! My colleagues on the circuit were also thrown by this patient, some of them didnt spot

the scar, and others thought he has hepatomegaly in addition to splenomegaly! So be careful
not to make up the signs if you are not convinced!
FINISHED MEDICINE on a massive high! Compared to all my other friends experiences who said
they were presenting as they walked out the door, I actually got time for a fair few questions,
and honestly said I couldnt have done better.

SURGERY- CHARING CROSS DAY 3 AFTERNOON

Everyone said that the surgeons were nicer than the medics, and previous Dr Clarke reports did
too, but I did not find this to be the case! On the whole they were quite antagonistic, stony
faced and wanted you to do things in their own specific way. My surgery didnt go as well as my
medicine- I nailed a couple of stations but the rest were so-so. I offered to talk through my
exams at the beginning and they seem happy with this, so I recommend you do this in Surgerymedicine is a bit of a different story. Will never forget the moments before it all started when
Prof Davies came in to give us a pep talk!
IMAGES AND INSTRUMENTS
First image right sided pneumothorax not tension- didnt know if examiner wanted a spiel, I
decided to just say the most obvious abnormality, but then later asked me if I thought the film
was well penetrated. Told her about chest drain insertion. She asked for causes of
pneumothorax. I think only had one image cant remember now. She put two tubes in front of
me- feeding and ryles NG tubes- talk about indications, insertion, and how to check it is n the
right place. Then placed two catheters in front of me- indications, wanted me to talk through
every step of inserting one! Smaller catheter which I thought was one for self intermittent
catheterization.
SHORTS
Funny examiner, very non bothered. Took me to patient in bed- asked quickly about his left
inguinal hernia repair, no recurrence. Did hernia exam, got him to stand, talked through
manoeuvres and anatomy. Next guy has a right leg that was twice the size of his left, very
indurated, erythematous, pitting oedema, also midline laparotomy scar, of large habitus. My
brain fell apart a bit at this point, talked about causes of lymphedema, he asked most likely
cause of swollen leg in this gentleman, had no idea and started talking about DVT for some
reason! A lady in a chair, bilateral hallux valgus and scars, aksed her about her symptoms and
previous operations. Got asked about hallux valgus and the options for surgery- bunionectomy
removal of the bursa, shaving of the bone and corrective osteotomy, asked how you would fix

it- didnt know- k wires apparently. Gentleman in a chair scar in the neck, I said carotid
endarterectomy. Examiner asked me what else scar could be for and what if the gentleman had
symptoms when lifting his arm- got into a discussion about subclavian artery stenosis/aneurysm
and subclavian steal syndrome. Asked me where the stenosis would be- I said proximal to
where the vertebral artery comes off. Then said this is indeed a carotid endarterectomy scar!
Aksed patient about TIA symtpoms- weakness, episode of visual loss, dysphagia, dysarthria.
Asked me which side symptoms would be on- got confused- eye symptoms on same side as
affected carotid, but contralateral weakness.
REST STATION- definitely feeling restLESS!
HISTORY STATION
Examiner was so old school! Just before we went in- he was like are you ready? Are you
confident? And I was raring to go
Started to take the history, examiner said and how would you like to address this gentlemanso I then had to ask the patient is it ok if I address you as Mr X- tedious! Presented over a year
ago with swelling of left testicle and pain in his left flank- left sided varicocele due to left renal
cell carcinoma. Also had some weight loss and reduced appetite. Carcinoma had invaded left
renal vein. Had left kidney removed year ago, later discovered that he had a met in the adrenalthis was removed couple of months ago, patient well otherwise. Taking fludrocortisone and
hydrocortisone- wearing medical alert bracelet saying no adrenal which the examiner told me
to look at- always try to look out for these things!!! Used to be an engineer at heathrow. I took
the history and summarized before the 10 minute bell, examiner looked delighted as he was
raring to get into the discussion. I explained the varicocele being due to invasion of the left
renal vein (robson stage III) and incompetence of the left testicular vein- I only really
understood this because of previous reports!! Score! Different types of RCC- mentioned SCC
because it said it in barrys book but apparently not- asked me where you find squamous cellapparently the trigone! Causes of scc- chronic irritation from stones in the bladder. Different
types of imaging he had- ct scan for staging, mra for the vessels, bone scan. Looking for mets?said PET scan. What is pet scan? Offered positron emission tomography didnt really know
much else- asked what does it look at- bluffed it and said oxygenated blood- apparently glucose
uptake! Said that being engineer could have exposed him to carcinogens like beta napthlamine.
Patients son died of cancer didnt get into the details, examiners asked me about if this could
have been an inherited syndrome- offered von hippel landau- wasnt convinced. He then just
said tell me about all the inherited cancer conditions you know- random! Started going on a
massive spiel about familial adenomatous polyposis coli, HNPCC, lynch syndrome- ovarian and
GI tumours, gardners syndrome- polyps and osteoid osteomas, he mentioned brca 1 and 2,
went on to wax lyrical about MEN I and II, what is MEN II associated with- neurofibromatosis-

he said yes von recklinghausens and what else would you look for- caf au lait spots,
neurofibromas, lisch nodules, evidence of bilateral acoustic neuromas. At the end he said well
done you clearly know your stuff. Are you interested in surgery- I reply with yes very much so
and am excited to have breast surgery as my first job, he said good dont just become a boring
old gp! I left the station flying high, nice to have a confidence booster especially after the dodgy
shorts, and all the time spent learning about random syndromes finally came to good use!
VASCULAR
As soon as I opened the door I recognized the vascular registrar- I had been with her in a clinic a
few times before- quite intimidating but respects a good candidate so I was put a little at ease.
Two patients in the side room. Examine arterial system of the legs- bilateral long medical scars,
vertical incision in left groin and could palpate a graft. Asked me anatomical landmarks for the
pulses that I was feeling. Put it together and said fem-pop or fem-distal bypass, stupidly said
with venous graft because of the long medial scars on both legs, doubled back to say synthetic
because I could actually feel it! I said that the Dacron graft was used because perhaps the long
saphenous veins were incompetent or had failed- she looked pleased. Took me to patient in the
other bed- asked to describe amputations- left below knee amputation and three toe
amputations on the right. Tell me about different types of amputation: digit, Ray-metatarsal,
ankle, below knee, above knee, hindquarter. What do they remove in a hindquarter- the whole
leg up to the hip joint- she added also the hemipelvis. Asked what problems I would council the
patient about before having the operation- long road to rehabilitation and walking, fitting a
prosthesis, neuropathic pain and phantom limb syndrome. Felt pretty good about this station.
ABDOMEN
Went into a small bay with two patients lying in beds next to each other. He took me to see the
one on the left, wasnt sure if I was going to examine both. By this point I think I was so excited
that I had started to get things right combined with the fact that I was on the cusp of finishing
finals, that I sort of forgot my schema for an abdo exam! I didnt make a good show of
inspection, and then remembered to do it just before palpation- a good thing I did because it
was an incisional hernia! Also forgot to auscultate- I think if you forget things in surgery it
matters way less than for medicine. Talked at length about incisional hernia- had a prepared list
of risk factors i.e. patient- immunosuppressed, diabetic and operations factors- length of
wound, site, development of dehiscence. This is where your prep really shows when they give
you a standard finals question, you real off a well rehearsed answer which gives you the time to
show off with more complex stuff! Then went onto talk about different types of closure (had
read a BMJ article about different methods of repair- closing individual layers vs mass closure)
and then briefly touched on mesh repair. Was not sure how this one went but glad we got to a
bit of discussion!

ORTHO
My last station of finals ever or so I hoped! Part of me was really dreading ortho, but I put in a
lot of really hard work to know my examinations back to front, know my anatomy and all the
common pathologies and follow up questions, so I was prepared as ever- BRING IT ON! Was
taken to this bay by this elderly Asian consultant, to see one patient, I figured it was going to be
a series of shorts but no we spent the whole ten minutes on this one patient. And what do I
get- not a knee, not a hip, not even a shoulder, a bloody foot and ankle! Thank god my paces
partner made me do some work on it so I knew about talar-tibia joints etc and some of the
movements. The examiner was fairly antagonistic throughout, contradicted me as I said that
the ankle joint was not just made up to tibio talar and that inversion and eversion also
happened at the ankle which I knew to be right! I told myself to calm down and just nod along
with him! The worst thing you can do in finals is to rile up your examiner because then they are
definitely not going to mark you well! And he asks me about the most obvious abnormalities..
guess what Hallux Valgus makes another appearance hoorah.. NOT! He asks me the same
questions I got asked in my shorts, I use the same few lines I memorized from Ramachandran,
saying bunionectomy and corrective osteotomy, and asks me for other options which I do not
know about it. He then spends several precious minutes asking me to examine the hallux and
first metatarsal which way is it valgus or varus? I tentatively say valgus having no clue Im so
confused which bone in relation to which bone hes talking about and then he keeps repeating
which way is it valgus or varus?, I was so confused and irritated that this was the way all my
hard work for finals was going down! I left the station relieved it was over but also thoroughly
infuriated about the ortho case, when I know I could have nailed a shoulder/hip/knee! Cursing
all the way to the pub lol!
I must have done something right and made it up for my other stations as I got a distinction in
surgery!
I came away with a score sheet that blew away my own expectations; I am not saying this to
boast, but to say that if I can do it, you can truly do it! Work consistently and not like a mad
man, being a well rounded individual who parties is just as important! Work SMART i.e. do the
work that will get you PACES points! I think I did well because I figured the right way to work in,
controlled my nerves, managed to be uber confident on the day and some luck!