The Insiders Guide to Passing Medical Finals at

Imperial College London 2010

By Emily Han Shao

1) Finals take place over three weeks at Imperial College London in June. The first week consists of three written
papers, the second week medical PACEs (equates to OSCEs in other medical schools), and the third week consists of
surgical PACEs.
2) Paper 1 is in the format of Single Best Answer aka Best of Fives, and Paper 2 is in the format of Extended Matching
Questions. Each paper consists of medicine (40%), surgery (30%) and pharmacology (30%). Medicine consists of 40%
because it also includes epidemiology. Paper 3 is a Practical Prescribing paper and as the name suggests consists
wholly of pharmacology. Papers 1 and 2 are each 3 hours long, whilst Practical Prescribing is 1 hour 15 minutes long.

3) Between 6 to 4 months before finals, depending on your revision style - whether you like to work slow and steady
or do everthing in one go. I would personally advise an individual to get themselves organised/ begin after Christmas
and really work hard from Febuary onwards.
4) The revision courses I went on really helped me plan my revision. I personally went on Mr Barry Paraskevas surgical
revision course and Dr Mirzas medicine revision course which took place over 10 and 8 weeks respectively. Mr
Paraskeva also writes the surgical section of the written paper for Imperial College students. Each course focused on
a section/ speciality each week and was accompanied by a revision booklet given in the first week so an idea would
be to read the section of the booklet to be covered that week beforehand, attend the revision session and then revise
over the weekend with the additional notes you made during the session accompanied by the Oxford Handbook and
Lecture Notes in General Surgery by Ellis, Calne and Watson.
5) My PACEs experience was overall a pleasant experience. Most examiners were helpful and aided rather than
hindered the student. My advice is if you meet an unkind examiner the likelihood is that they treat all students they
examine like this so just do your best.

6a) My PACEs cases:

Medicine (Chelsea and Westminster)
CVS: Aortic Valve Replacement
Resp: Chronic Obstructive Pulmonary Disease

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Abdo: Liver Transplant with two incisional hernias (was more of a surgical case but apparently also came up last year
in medical PACEs at Chelsea and Westminster)
Neuro: Multiple sclerosis
Shorts: 1) Panphotocoagulation for diabetic retinopathy 2) Gynaecomastia (Questions asked - how can you
differentiate between true and false gynaecomastia, what drugs can cause gynaecomastia (answer egs. steroids,
sprironolactone, digoxin)) 3) Cellulitis 4) Cushings syndrome (Questions asked: whats the difference between
Cushing's Syndrome and Cushing's Disease; What visual field defect would be expected with Cushing's Disease) 5)
Rhematoid arthritis hands
History: phaechromocytoma
Surgery (Charing Cross Hospital)
Abdo: Incisional hernia
Vascular: femoral - polpiteal bypass
Orthopedics: osteoarthritis of the knees
Instruments and Images: 1) ERCP showing dilated biliary ducts and gall stones (ascending cholangitis); 2) Contrast
barium enema showing apple core lesion (adenocarcnoma of the rectum) 3) Chest X-ray - tension pneumothorax
(question - how would you manage this; answer: large borne cannula through second intercostal space, mid clavicular
line) 4) urinary catheter - male and female 5) oropharangeal airway 6) Nasopharangeal airway . There were more (I
think I went through about 12 cases) but none that I remember that were surprises or were not covered by Mr Barry
Paraskeva.
Shorts: 1) Fasciotomy scars with knee replacement scars (pt had compartment sydrome due to damage to popliteal
artery during knee replacement) 2) Loop Ileostomy 3) Arterial ulcer
History: Previous breast Ca with masectomy
6b) Cases other students had:
MEDICINE (chelsea and westminster)
history- polymyalgia rheumatica
resp- pulmonary oedema
cardio- Mitral stenosis
abdo- cirrhosis
neuro- spastic paraparesis (MS)
shorts- RA and pan retinal photocoagulation
SURGERY (Charing Cross Hospital)
history- intermittent claudication and bypass
abdo- polycystic kidneys, nephrectomy, fistula
vascular- af and upper limb
ortho- knee OA
shorts- OA, open repair AAA, LD flap and breast reconstruction, RA

Medicine (St Mary's hospital)

1. Shorts: acromegaly, ascites
2. Cardio: Aortic stenosis

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3. Resp: bronchiectasis
4. Abdo: hepatosplenomegaly
5. Neuro: SLE with peripheral neuropathy and unilateral choreiform movements
6. Hx: coeliac disease
Surgery (St Mary's hospital)
1. Shorts: varicose veins, hockey-stick scar, hallux valgus, weird bony lump behind 5th CMC (no idea what that was),
AV fistula
2. Abdo: Subtotal colectomy with end ileostomy
3. Vascular: axilofemoral bypass
4. Ortho: Hip OA
5. Instruments and Xrays: no surprises..the usual stuff
6. History: rectal ca

7) At Imperial a vital part of preparation for exams is finding tutors and getting into tutorial groups. Try to sort this
out early before Christmas in final year. Advice I myself received from older years was instead of getting into groups
of 4 or 5 aim for smaller groups of 2 to 3 as getting into larger groups can frequently mean in two hours you yourself
have only examined on patient, and there may not be enough patients (due to patient's declining, or gone for
procedures) per session for everyone in the tutor group to have seen a patient. However bear in mind this also
depends on how many students your tutor prefers to teach!

8) ACE the OSCE was extremely helpful for my personal revision as its great to have a resource on what should be
done to guide you in your revision before bothering the patients!

Insider guide to passing Imperial Finals 2008

Contents
Personal Accounts
Dr Edward Armstrong p2
Dr Peter Milton p5
Dr Hetul Shah p8
Dr Jannake Sivajee p13
Dr Sivatharjini Sivarajasingham p15
Presenting Images and Instruments

Presentation of an abdominal radiograph p22

Presentation of a double-contrast barium enema with an apple core lesion p23
Central Venous Pressure Line (CVP) p23
Endotracheal Tube p23
Nasogastric Tube p24
Proctoscope p25

Dr Edward Armstrong
1) Exam information regarding the question type and how the marks are allocated for each paper (i.e. what
percentage of the marks are allocated to medicine/ surgery/ ethics/ epidemiology/ pharmacology etc.)
Medicine:
2 written exams (each 2 hours)
1 clinical (PACES) exam (70mins)
First medicine paper: 120 Single Best Answer questions
Second medicine paper: 175 Extended Matching Questions
Each written paper roughly:
60% General Medicine
20% General Practice
20% Epidemiology and Public Health
Pharmacology
One 3 hour written exam (175 questions)
Surgery
1 written exam (3 hours)
1 clinical (PACES) exam (70mins)
2) When you should start revising
Length of time needed to achieve
i. Pass (2 months)
ii. Merit (4-6 months)
iii. Distinction (4-6 months)
3) How do you plan your revision over such a long period of time?
It is very difficult to plan your revision over such a long period of time. My advice would be over
Christmas holidays or at the start of January to make a long list of all the topics you need to cover.
Then work out how much time you have for each topic. Start slowly. You still need time to enjoy
yourself in the graveyard months of February and March. The adrenaline will kick in during April and
May. Be flexible with your timetable and allow for changes as you progress. Start with unfamiliar or
weak topics. Try to cover pharmacology and medicine topics in tandem. There is a significant amount of
repetition and it helps to reinforce your knowledge.
6) Your thoughts/ feelings after each exam.
Following medicine writtens, I felt pleased that I had concentrated on Epidemiology and Public Health as
this was 20% of both papers. The SBAs were hard, especially as time was a real pressure. EMQs were
much easier. Following the written exams, I would suggest that future candidates allocate sufficient
time to Epidemiology and Public Health and make sure they do plenty of practice questions as the EMQ 5

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paper was full of "buzz words" which you will only pick up by doing questions.
Following the Pharmacology written exams, my feeling was that the exam was fair. If you had done the
work, then it was not a difficult or tricky exam. Three hours was adequate to get through the exam.
Surgery writtens were also reasonable as long as you had done the work, but there were plenty of trick
questions so it was important to read the questions and options carefully. Again, time was sufficient.
Medicine clinical exams were built up to be difficult with scary examiners. The cases were all reasonable
and the examiners were not intimidating. Just ensure that you are very good with your examinations.
We had 10 minutes per station and this goes extremely quickly.
Surgery clinicals were very different with less obvious structure to each station, compared to the
medicine clinical exam. But the examiners guided you through and asked reasonable questions. Again,
10 minutes goes very quickly.
7) Describe your PACES experience/ how the examiners treated you and what cases you were given.
MEDICAL PACES
CVS:
Aortic valve replacement with a mechanical valve. Patient also had Dupytrens contracture.
Questions on Aortic Regurgitation, Duputrens, Symptoms indicating severity of AS.
Resp
Pleural Effusion with signs of Chronic Liver Disease.
Questions on causes of pleural effusion, other features of chronic liver disease.
Neuro
Ulnar nerve lesion with wasting of small muscles of hand.
Questions on muscles supplied by ulnar nerve, investigations to confirm diagnosis.
Abdo
Renal transplant with scars from previous peritoneal dialysis, no signs of ciclosporin or steroid use.
Questions on causes of end stage renal disease, how to manage diabetes, ACE inhibitors method of
action, side effects of ciclosporin.
History
History of AS with Aortic Valve repair. No other significant medical problems. Had some complications
on warfarin and had angiodysplasia.
Questions mainly on AS and effects on activities of daily living.
Short Cases
SURGERY PACES
Abdo

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Patient with an iliostomy and a parastomal hernia.
Questions on indications for iliostomy, problems with stomas, symptoms and signs of prolapsed or
retracted stomas, signs, symptoms and investigations for small bowel obstruction.
Vascular
Varicose veins, in a patient who already had a high tigh and stripping. Also had some arthritis in hip
and knee.
Questions on indications for varicose veins operations, different types of varicose vein operations,
investigations for varicose veins.
Orthopaedics
Osteoarthritis of knee with fixed flexion deformity and small knee effusion
Asked questions on symptoms of OA, differential diagnosis of leg/knee pain. What else is important to
exclude, when would someone be suitable for a total knee replacement.
History
Patient with previous low lying rectal carcinoma.
Questions on different types of histological findings of colorectal cancer. Different symptoms of different
sites of colorectal cancer.

Images and Instruments

Shorts
8) Additional advice
My advice for final years would be:
For writtens, make a good plan of what to get through. Ensure you give time to consolidate topics
already covered. Dont worry if you feel pressured. In Feb, March allow time for nights out, birthdays,
films etc. Even in April make sure you take some time off e.g. a weekend away somewhere.
For clinicals, get two good tutors for medicine and surgery. Seeing cases is invaluable for PACES as you
will have seen many of the cases or signs before. Ensure that you have regular times with your tutor
who will show you several different cases per week. Try and make sure they are a registrar or
consultant (you can supplement this by also having an HO or SHO).
The night before, make sure your friends give you a mock PACES. It was so helpful as it was actually
really nerve-racking having to do an exam with your friends acting as examiners and patients. It also
demonstrated that 10 minutes is very short and there is not much time for questions, or long winded
answers.
Do continue to go into clinical placements while trying to revise. You can use this as an opportunity to
see more signs and to consolidate some aspects of your revision. Try and get a member of the team to
give you some bed side teaching or to ask you questions on the cases your team is looking after.

Dr Peter Milton
1. When you should start revising
Naturally, the more work you do for these exams the greater the likelihood of a good pass. However the
relationship between time devoted, or material covered, and outcome is a concept devoid of any merit.
Firstly, in considering this question as how not to fail then one should avoid falling under the category
of globally weak finals will test your knowledge of medicine and surgery in the broadest sense; thus
ensure you address all areas of the syllabus with equal enthusiasm and energy. Aim to turn your
weakest subjects into your strongest! Ultimately, the amount of work required for finals in the first
instance will depend on your attitude to learning in the preceding years; those that covered the third
year course diligently will be in a strong position but one should note the weighting toward
management is greater in finals. If you havent already done so, it would be advisable to work your way
through the third year online lectures early in your final year before addressing the final year revision
lectures later on (there is, however, considerable overlap in content). To achieve competency in a topic
will be relatively painless, however the amount of work required to achieve a 'merit-level' of knowledge
in any one area is proportionally greater and thus a sniper approach, identifying core concepts, is
advisable over the cluster bomb attack of kumar and clark! So, with that said, final year more than any
other is a year to work diligently from start to finish for all the crammers out there, now is the time to
change your spots. In the run up to exams, 12 weeks is a reasonable amount of time to realistically
cover everything comfortably but make sure you gradually increase the pace of your revision to peak in
the weeks prior to your finals and not burn out 6 weeks in. Traditionally the final year dinner is the date
in the diary beyond which social events make way for study plans.
2. How do you plan your revision over such a long period of time?
Identify your syllabus. As previously mentioned the third and final year intranet lectures are a good
starting point. Be realistic in the significance and volume of each topic when allocating revision time,
particularly when you get closer to the exams. With regards medicine, one of the Profs reviewed past
papers over a three or four year period and produced a breakdown of the weighting of the exam
questions, most common to least:
GI
RESP
A+E/EMERGENCY
CVS
NEURO
GERIATRICS
ENDO
RHEUMATOLOGY
HAEMATOLOGY
RENAL
TROPICAL DISEASE
HIV

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ONCOLOGY
ALLERGY

3. What books/material should you use for each exam and why did you find these useful?
Intranet lectures and grand rounds are fantastic as a base and a guide to the areas of each topic upon
which the examiners place emphasis; they are also fantastic when you just dont want to pick up a
book.
Find medicine and surgery tutors, whether they be registrars or consultants, and ensure they are
committed to the cause and in it for the long haul. Tutorials will identify areas of weakness and uncover
misconceptions. Ensure your study group is well balanced, motivated, has similar aims and challenges
you else you will not benefit fully from your tutorials.
4. Are there any books that you would perhaps advise to avoid and why?
If I were to do anything differently I would not use onexamination.com under any circumstances; I
found the questions to be poorly written and feel strongly that they divert your attention away from the
core concepts with repetitive focus upon minutiae.
Medicine at a Glance was my worst text purchase while it widely heralded as the most commonly
used core text for finals it serves to prove the point that if you dislike the narrative and style of a book
then it is worthless. I disliked learning anything at a glance and found the lack of depth and explanation
frustrating.
5. Describe your PACES experience/ how the examiners treated you and what cases you were given.
Medicine
History
Incontinence secondary to resection of prostate (Ca). Extremely surgical in nature which threw me
somewhat, although very straightforward. Questioning focused upon pharmacology.
Cardiovascular
Elderly gentleman with mixed AS/MR.
Respiratory
Pulmonary Fibrosis
Gastrointestinal
Liver transplantation with/without kidney transplantation.
Neurology
Cerebellar ataxia motor deficit.
Shorts

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Graves' disease
Iatrogenic Cushings
Ankylosing Spondylitis
Retinitis Pigmentosa
Hypertensive flame haemorrhages
Surgery
History
Intermittent Claudication
Instruments
Endotracheal tube, shouldered syringe and phenol in almond oil, Austin-Moore prosthetic
Images
Pleural effusion (unilateral), R total hip replacement with contra lateral signs of OA, pulmonary fibrosis,
IVU and requested control
Dr Hetul Shah
1. Exam information regarding the question type and how the marks are allocated for each
paper (i.e. what percentage of the marks are allocated to medicine/ surgery/ ethics/
epidemiology/ pharmacology etc.)
1. Medicine- including General Practice & Public Health Medicine.
Paper 1 - 2 hours (Morning)
Single Best Answer (SBA) format.
120 questions: 80 General Medicine, 20 Public Health, 20 General
Practice.
Paper 2 2 Hours (Afternoon)
Extended Matching Questions (EMQ) format.
150 questions: 100 General Medicine, 25 Public Health, 25 General
Practice.
2. Clinical Pharmacology & Therapeutics 3 hour paper
SBAs 75 questions
EMQs 100 questions
3. Surgery - 3 hour paper
SBA 75 questions
EMQ - 100 questions
2.

When you should start revising to achieve:

a)
b)

Pass 4 months before first paper

Merit 5 months before first paper

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c)
3.

Distinction >6 months before first paper

How do you plan your revision over such a long period of time?

1. For the written papers

This requires some old-fashion book work. Medicine has at least twice the content of Surgery and
cannot be done without considering pharmacology. Hence I divided most my time for medicine- taking
each system at a time (eg. Cardiology, respiratory, etc) and doing the relevant pharmacology revision
with this. This reinforced the learning.
2. For the practical exam
At Imperial we have a PACES style exam which requires not only examining the patient but also has a
viva-style grilling throughout (see Question 7). I formed a revision group with three friends with whom
we practiced all the system examinations regularly for about 5 months before the exam. We met at
least once a week and the repetition was important in becoming slick at examining.
Once a week we also had tutorials in medicine and surgery with a consultant. Here we saw patients and
had exam-style viva.
This combination of book work, practicing on friends and seeing patients with a consultant allowed to
put the theory work into practice and made the months of revision tolerable.
6.

Your thoughts/ feelings after each exam.

Medicine:
Despite the general consensus, I thought the medicine papers were okay. Not easy- but fair. There was
a good mixture of easy, medium and difficult questions. Most students were upset by being unable to
answer the few difficult questions. However it is important to realise there have to be some impossible
questions to differentiate between candidates. Trust your gut instinct when answering the questions.
Keep an eye on time as it goes quick. Before each exam work out how long you have per question on
average and be disciplined in sticking to it- for example, for paper 1, I minute per question.
Clinical Pharmacology & Therapeutics:
I almost laughed walking out the exam as the questions focussed only on content from the web lectures
(Question 4). Time was not an issue.
Surgery:
As for Medicine, most students also complained about this paper. It was tougher than expected- but
remember that everyone is in the same boat and everyone has pretty much the same knowledge base
(because you all use the same books). I think besides two or three questions, all questions were
answerable using first principles. However many were thrown by the few bizarre questions, for example
on what type of current diathermy works on. It is okay not to be able to answer every question- keep a
calm head and move on. Time was a bit more of an issue- again important to be disciplined with
answering questions.

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7. Describe your PACES experience/ how the examiners treated you and what cases you
were given.
Medicine
5 examination stations, each 10 minutes long (6 minutes for examination and 4 minutes for viva). The
history station was 20 minutes long (14 minute history taking and 6 minutes discussion). I minute to
transfer between stations. There was one 10 minute rest station

Cardiology: Mechanical Mitral Heart Valve- could hear it without a stethoscope! A straightforward
cardiovascular exam and discussing the implications of a mechanical valve and comparisons with tissue
valves.
Respiratory: Patient with pneumonectomy- absent breath sounds and deviated trachea. Discussed
possible reasons for pneumonectomy and what I would expect to see on chest radiograph.
Abdominal: Patient with nephrectomy scar with tenckhoff catheter in situ (for peritoneal dialysis)difficult to piece together unless you had seen dialysis patients during the final year Renal firm.
Discussion of other management modalities for patients with chronic renal failure, such as
haemodialyses.
Neurology: Motor Neurone disease- simple upper limb examination with differentials. Not much time
for discussion as examination is rather time-consuming.
History: Patient with Angina- quite straight forward focusing on risk factors. We discussed
management of myocardial infarction.
Short Cases: (5 minutes each): Fundoscopy- Retinitis pigmentosa- I had luckily read about this
condition. The eyes were dilated and having practiced on friends with non-dilated pupils, it was fairly
straightforward.
Rheumatology- Rheumatoid Arthritis (hand signs and nodules on elbows). We discussed differential
diagnoses (ie psoriatic arthritis).
Surgery
Six stations, with one ten minute rest station, as for Medicine.
Abdomen: Patient with a Colostomy- very straight forward so make sure you learn how to examine
stomas. We discussed the indications and complications of stomas.
Orthopaedics: Patient with malunion (valgus deformity) following a compound fracture of tibia. This
was pretty tricky to examine because there is no special examination for a deformed lower leg. It was

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important to remain calm and use the 'look, feel and move' principles, as well as assessing gait and
foot pulses. However, most the exam consisted of a viva on fracture management and complications.
Vascular: Examination of the legs- long incision scars from fasciotomy following compound fracture. I
was confused because it wasnt a typical vascular case and found the examiner unsympathetic.
However we discussed possible differentials of a patient with calf pain and the management of
compartment syndrome.
History (20 minutes, as for Medicine): Intermittent claudication- focusing on risk factors for arterial
disease. We discussed management of the ischaemic foot which was very straightforward.
Short Cases: Less structured than Medicine. I examined 3 patients; first a patient with ulnar nerve
palsy (hand signs and Froments sign); secondly a patient with cervical spine restricted movement
(discussion of differentials, Osteoarthritis, Rheumatoid Arthritis and Ankylosing Spondylosis); and lastly
a patient with Dupytrens contracture.
Images/Instruments: Perhaps the most daunting station- but actually the easiest to prepare for. The
first 5 minutes included going through radiology on the computer system.
The images included plain abdominal radiographs, barium meals and follow-throughs and KUB films.
There was no CT/MRI although it is possible to get simple CT heads- such as of subdural haematoma
The last five minutes involved identifying surgical instruments and talking about their uses.
Instruments included chest drains, sutures and blood culture bottles. The point of this part of the exam
was to see if you had been on the wards. The third year section of the Medical School website has
pictures and descriptions of each instrument that will appear in the examination. In preparing for this
exam, I practiced presenting the equipment in my small group.
In general the examiners were friendly and helpful. The surgeons preferred for us to talk through the
examination, whilst the medics preferred an end-of-examination summary (though there were
variations). Hence, it is important when practicing each examination to do so both silently as well as
talking as you examine. Each station is assessed independently, so performing poorly in one station
does not mean you have failed. It is important to put each station out of your mind and focus on the
next.
There is about a week of revision time between the written exams and medicine PACES, and a further
week before the surgery PACES. This is adequate time to prepare. We met in our group on alternate
days to practice our examination routines and viva each other on things like instruments and
radiographs. On the off day I skim read through my notes to prepare for the viva aspect of the exam.
8.

Additional advice

As explained above, it is important to draw up a timetable early on to ensure you can get through
everything. There is a phenomenal amount of content to cover. The best advice is to start early. I
started work at a cautious rate after my elective in November. This meant I wasnt panicking towards
the end. Get your friends together early in January to start going through the examination routines. It
is like practicing for a show I suppose- you should be automated by the end so you can concentrate on
finding signs. The only way to do this is repetition. Try and work together as a group so everyone is
revising similar topics at the same time. This not only gives the group common targets and motivation,

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but also allows to iron out any queries. Try to organize your week so that there is variety and you are
not sitting in your room studying alone for days on end. Organize a tutor early (they are snapped up
quick). Do not have more than one tutor each for medicine and surgery as you end up traveling from
site to site and waste valuable time and energy. Finals is a marathon and not a sprint. Do not burn
yourself out from the outset- slow and steady wins the race. And lastly, look after one another. It is
amazing how subliminally ruthless we can be to each other. Do not try to panic others- instead help
each other out. Remember that finals is not some sort of competition- everyone wants to and should
pass. Good luck!

Dr Jannake Sivajee
1. Exam information regarding the question type and how the marks are allocated for each paper (i.e.
what percentage of the marks are allocated to medicine/ surgery/ ethics/ epidemiology/ pharmacology
etc.)
Medicine SBA, EMQ
Equal weighting for both papers
It also includes 5 EMQs of epidemiology
Each paper is 2 hours long. The papers are taken separately; one in the morning and one in the
afternoon.
Surgery- SBAs and EMQs in a single 3 hour exam.
Pharmacology SBAs and EMQs in a single 3 hour exam.
2. When you should start revising
It doesnt really matter when you start working as long as you work hard. Usually the earlier you
start the better. As I was in the last group for elective I started revising a few weeks after
coming back in January. Some people find that they get a bit bored if they start revising too
early. Do whatever works for you.
3. How do you plan your revision over such a long period of time?
It helps to make notes on subjects in which you have had an attachment during the year.
4. Are there any books that you would perhaps advise to avoid and why?
No. Any book is good
5. Your thoughts/ feelings after each exam.
Medicine: The SBA paper was a hard paper, especially as there was always two answers you
could narrow it down to, but it was so hard to choose (the whole point of the question).
The EMQs were better in comparison, but still tricky.
Surgery: It was very different to the mock that we had sat earlier in the year. I have never had
to think that hard to answer a paper ever before. It was also the first time I have ever used the
same answer more than once (some even 3 times). There were quite hard stems - one of them
being about imaging of gastro system which was especially difficult.
Pharmacology: As this was the paper I had least revised I was dreading it. Doing webCT
apparently helps but not a great deal when you try practice questions (especially as I don't think
it is taught well). The paper was however much better than I had expected as I was actually able
to answer a few questions.

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6. Describe your PACES experience/ how the examiners treated you and what cases you were given.
Medicine PACES were ok. However, as they were the ones that I had more practice on I felt I
didnt do as well as I could. It was quite different to doing it with your tutors. They didnt stop us
to ask questions or hurry me up. Sometimes there wasnt much time to ask questions. The
neuro station had very vague instructions, which meant that you left the station not knowing if
you were supposed to have done something else.
There was some confusion in my last station. I was in the last circuit of the afternoon and the
patient had left early! I had to wait till the exam was over and everyone had left to go and
examine a patient in another circuit. On the whole the examiners were nice. The patients were
also really friendly.
CASES
Neuro: Cerebellar disease
Shorts: 1. Diabetic retinopathy. 2. Rheumatoid arthritis
History: Rolycythaemia with questions about hypopituitary disease
Respiratory: Apical pulmonary fibrosis
Cardiovascular: Tissue valve replacement
Abdominal: Hepatomegaly +/- splenomegaly
Surgical PACES were better. It was a nice feeling to leave exams on a good note, as surgery is the last
exam. The doctors and patients were very nice. There was plenty of time for the history station.
Everyone got to do 3 shorts. Most of them preferred us to talk through what we were doing but they
told us that with the instructions. The x-rays and instruments station was quite tricky as the images
were really odd. The instruments were fine if you had looked through the instruments on the intranet.
Again in my last station the just as the bell was about to ring the patient left to go to the bathroom,
which was fine with the doctor as she said shed start with the discussion. I was slightly thrown at the
beginning as I was talking about orthopaedics and probably what the patient had before I had
examined him, i.e. I was doing the station backwards to what I had practiced. However it was fine as
you get the discussion over and done with. Surgery PACES was different in the way that you examine
basically just what your asked to; you dont have to go from the beginning if they tell you not to.
CASES
Vascular: Fem pop bypass + fasciotomy scars
Shorts: Arthrodesis, nerofibromatosis, fem pop bypass
History: Past medical history of a ruptured AAA
X-rays & instruments: Thoracic aortic aneurysm; Cardiomegaly; fractured radius and ulnar fixed with
plates; rectal stent; endotracheal tube
Abdomen: Colostomy for Crohns disease
Orthopaedics: Osteoarthritis of the hip
8. Additional advice
It is quite hard to juggle commitments. As the exam gets closer you have little social life. Its
worth trying to arrange tutorials on the same day for both surgery and medicine so you dont
have to travel on different days. This is quite hard however and you may find that you try to
arrange teaching whilst you are in the hospital for something else.

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Dr Sivatharjini Sivarajasingham

Exam information regarding the question type and how the marks are allocated for each paper (i.e.
what percentage of the marks are allocated to medicine/ surgery/ ethics/ epidemiology/
pharmacology etc.)
The Medicine exam is split into two parts: a single best answer (SBA) paper and an extended
matching questions (EMQ) paper. The SBA paper lasts 2 hours and consists of 120 questions; the EMQ
paper also lasts 2 hours but consists of 150 EMQs.
In 2008 the general consensus of the final year was that the SBA paper was much more difficult than the
EMQ paper. I believe this was due to a number of reasons, including:
Time is tight (1 minute per question)
Medical students are less familiar with SBAs than EMQs.
I felt that the SBAs focused more on minutia than EMQ.
The EMQ paper was in contrast easier than I anticipated with some questions that I believe could have been
part of a 3rd year EMQ paper.
20 SBAs and 25 EMQs on epidemiology feature in the medicine papers. I would therefore advocate
attending the epidemiology lectures and actually learning some of the important information as they will
feature in the exam and can be easy marks to gain.
The Surgery exam lasts 3 hours and contains 75 SBAs and 100 EMQs. The paper that we faced included
an unexpected mix of questions with much focus on Orthopaedics, Ear, Nose and Throat and Breast. It was
definitely a more varied paper than the mock paper that we undertook in a revision session with Mr
Paraskeva and Mr Purkayastha. Therefore to be best prepared it is advisable to not ignore any aspect of the
surgery syllabus as they may feature disproportionately in the paper.
The Clinical Pharmacology and Therapeutics exam also lasts 3 hours and contains 75 SBAs and 100
EMQs. This paper was fairly set with our years average mark being 73%. There was much focus on side
effects in particular those of cytotoxic drugs.
For information on merits and distinctions, check the intranet as the requirements are changing from 2008/9
onwards. In our year, to get a merit in medicine and sugery, you needed to be in the top 25% of candidates
in the written exams and obtain an A grade in PACES. In CPT, you had to be in the top 20% of candidates.
2.

When you should start revising to achieve:

a)

Pass I believe you can achieve a pass by starting to revise solidly from March onwards.

b)

Merit I think you would need to start revising from January.

c) Distinction I think you need to probably start from October.

The above suggestions are totally variable as everyone works in different ways, so I dont think there is any
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hard and fast rule.

3.

How do you plan your revision over such a long period of time?

I think the most important thing to do before planning your revision is first to chose one textbook for each
subject that you like to work from. You can then set up a plan using the topics in the textbook as a simple
guide. It is probably advisable to give or take two to three days for each topic as some topics you may like
and therefore whizz through however other topics that may be shorter in length, may challenge you a bit.
For pharmacology I did not use any textbooks and instead dedicated a week working intensively on the CPT
lectures on the intranet. I also used the pre-typed up pharmacology notes and Garrys notes found in the
shared gmail account.
Closer to the exam dates you want to be practising your examinations as much as possible on patients and
even on each other. This is vital as most students who fail overall usually do as result of failing one of their
PACES exams. There have been students known to gain A grades in their written papers and fail their
PACES as they simply havent practised their examinations enough.
6.

Your thoughts/ feelings after each exam.

After my medical SBAs paper I was most disappointed, rather worried and despondent as it was without a
doubt the hardest paper I sat during my medical finals. I was only slightly encouraged by the fact the rest of
my year also found it a difficult and a rather obscure paper. The EMQ paper was more encouraging and "doable".
The pharmacology paper was fair but required a sound knowledge of adverse effects and drug interactions.
The surgery paper was a mixed bag of some expected and unexpected questions, so although I was
surprised by the content of the paper, I still thought it was passable.
After each of my PACES exam I felt quite indifferent as I found it difficult to truly judge how each station
went.
7. Describe your PACES experience/ how the examiners treated you and what cases you were
given.
Medicine PACEs (Chelsea & Westminster)
1. Respiratory Station: I carried out a complete respiratory examination on a slim gentleman with
normal respiratory rate, no scars and no other respiratory paraphernalia. On examination my only
finding was crepitations in the apices especially on the left. The examiner then asked me the causes
of apical fibrosis and asked me to look at the gentlemans arms more carefully. I noted that there
were increased bruising on his arms, she asked what these could be caused by, I stated that the
usage of corticosteroids could be a cause. The next question was what do you use steroids for and
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then she asked me to think of vasculitides, and I managed to mention Wegeners Granulomatosis
which was the diagnosis. The examiner was nice enough and guided me well to the eventual
diagnosis.
2. Abdomen Station: There was an elderly gentleman who was partially deaf who was very slim with a

distended abdomen. The patient had subconjunctival pallor, some tenderness on deep palpation
especially on the right and left flanks. I was unable to palpate either liver or spleen, however on
percussion I noted the spleen extended across toward the right iliac fossa. Shifting dullness test was
negative. I presented my findings and the examiner asked me the causes of splenomegaly. The
examiner asked me which option was likely (considering the anaemia and the patients age) and
then she asked how I would further investigate. The examiner was encouraging and friendly.
3. Neurology station: Upper limbs examination on a well looking gentleman seated in a chair. Whilst

examining the examiner interrupted a few times with questions about the nerve roots supplying
certain muscles & reflexes. Findings were all normal apart from hypotonia bilaterally and point
passing on testing of coordination. I was asked for the most likely differential diagnosis (cerebellar
syndrome) and also what else I would like to examine (gait, eye movements and formal testing of
speech). The examiner then asked about what further investigations I would like to do (imaging) and
whether a CT or MRI would be better. Finally the examiner asked me to examine the patients
lumbricals. Once again the examiner was friendly enough however he was much more interactive
than the others.
4. Short Cases: First short case: Fundoscopy of a patients left eye. Findings included flame

haemorrhages and hard exudates. Unfortunately my examiner was rushing me throughout the
examination. I presented my findings and stated I hadnt looked into the peripheries because of time
constraints. The examiner then asked me to look into the peripheries which I did and noted that there
were dark pigmented patches in the peripheries. I was then asked for differentials
(Photocoagulations scars, Retinitis pigmentosa.)
Second short case: A middle aged lady with well demarcated erythematous scales on extensor
surfaces of forearms, elbows and knees. Diagnosis: Psoriasis. I was then asked what psoriasis looks
like under the microscope and how to manage psoriasis. I was asked about other complications of
psoriasis (infection, psoriatic arthritis) and the nail changes seen in psoriatic arthritis and why.
5. History station: A middle aged gentleman who had some speech difficulties with a very complex

history including polycythaemia rubra vera, hypopituitarism and stroke. It was quite difficult getting a
clear history from the patient due to the speech difficulty however the examiner was very
understanding of this and did interrupt the patient in order to help me out. After the patient left the
room, I presented a summary of the history and then we discussed hormone replacement in
hypopituitarism. The examiner also asked if I had noticed anything else about the patient- the patient
had a Cushingoid appearance (which is unlikely in hypopituitarism), and we discussed the possible
causes (ACTH producing pituitary tumour etc.) This examiner was particularly friendly and really did
succeed in putting me at ease. The discussion was done in quite a casual manner.
6. Cardiovascular station: Examination findings included sternotomy scar, atrial fibrillation, and a loud

first heart sound, apex beat not displaced. There were no obvious added sounds, no collapsing pulse
and no raised jugular venous pressure. I presented my findings and was asked for differentials
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(mitral valve replacement [autologous].) I was asked how I would confirm my clinical findings
(echocardiogram) and then about which valve murmurs caused displaced apex beat.
Surgery PACEs (Charing Cross Hospital)
1. Abdomen Station: This station was without a doubt the most bizarre experience of all my PACEs
stations. The examiner was very interactive but asked unpredictable questions, including why
Virchows node was mostly associated with intra-abdominal malignancies and who Virchow was. I
was also asked where the word Pfannelstiel originated from and how to examine for a distended
bladder. This station was the least structured and I did not even have the time to complete my
examination.
2. Orthopaedics Station: I examined a gentlemans hip and my findings included a long scar down the

lateral aspect of the patients right thigh which I initially mistook for a total hip replacement scar. The
examiner then asked for what that scar could be for (approach to the femur) and I presented my
findings. The discussion then moved onto the management of an elderly patient presenting with hip
pain in an acute setting and finally concluded with the surgical options available for different types of
fracture.
3. Vascular Station: I was asked to examine the lower limbs having been told the arms and the carotid

arteries were normal. My findings included venous eczema, haemosiderin deposition, several scars
(R femoral scar, R medial thigh scar, bilateral fasciotomy scars, paramedian abdominal scar). On
palpation there was prolonged capillary refill (5 seconds) and a right aorto-femoral synthetic graft,
with some pulses not palpable. I carried out the Buergers test which was positive. The examiner was
very responsive to my answers and very encouraging. He went onto ask about how to manage
chronic ischemia.
4. Shorts:
First short case: A patient who had a bony deformity of the left lower leg with associated fasciotomy scars.
I presented it as a poorly healed fracture of the tibia post trauma. The discussion then moved onto the
complications of fracture healing and what factors promote poor healing.

Second short case: I was asked to examine the patients hands having looked at the patients elbows.
Patient had bilateral scars near the elbow and so I examined the patients ulnar nerve. Patients had partial
nerve palsy as there were no signs apart from reduced power on adduction of the little finger. I was asked
what could have caused this and what investigation (nerve conduction tests) I would like to do to confirm my
clinical findings.
Third short case: I was asked to describe the lesions visible on the patients skin. The patient had multiple
nodular lesions all over the chest, arms and face. Diagnosis was neurofibromatosis and the examiner asked
what else I would like to look for: I looked under the axilla for axillary freckling and also for caf au lais spots.
I was asked how many caf au lais spots are required for diagnosis (6 spots) and whether neurofibromas
can be operated on.
In between stations I was asked to classify spinal cord tumours (primary/secondary) and which neoplasias
commonly metastasise to bone.
Fourth short case: I was asked to inspect and state what I could see on this patients legs (bearing in mind
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I had 30 seconds left). I noted venous eczema, onocholysis, and a left medial thigh scar. The examiner
asked for a diagnosis and I presented it as mixed arterial and venous disease with long saphenous vein
harvesting. The examiner was nice enough to let me know that was the correct diagnosis.
5. History: The history was from a 72 year old gentleman with a complex vascular history including

coronary artery bypass graft, endovascular aneurysm repair (with complications including embolism
causing a necrosis of the little toe requiring a ray amputation), an abdominal aortic aneurysm which
fistulated into the duodenum causing haematemesis and eventually ruptured requiring open repair.
He also had a valvotomy. I presented a summary of the history and follow up questions included how
to follow up patients with abdominal aortic aneurysms, when to operate and complications of
aneurysms. The examiner was again very encouraging.
6. Images and Instruments: The images I interpreted included a left hip fracture, small bowel

obstruction, a series of CT images of the brain showing ring enhancing lesions (examiner asked for
differentials) and a complicated bilateral hand x-ray.
Instruments: Nasopharyngeal airway and oropharyngeal airway (I was asked which one I would use in the
more conscious patient). A lumbar puncture needle, a Dacron trouser graft, a colostomy bag and a shoulder
injection (the examiner asked me why the shoulder injection was designed as so!)
8. Additional advice
I think it vital to organise yourselves into small tutor groups of people you work well with (this may not
necessarily be friends) and to approach tutors for both medicine and surgery well in advance. I found these
tutor based tutorials extremely useful, particularly when the stress levels were high. The tutors also gave
useful guidance on how far along you should be with your revision.
As the exams get closer there is a sudden influx of medical students into all the Imperial hospitals especially
the centrally based ones, and there is fierce competition to see patients with good signs. Hence both staff
and patients get rather irritated. To avoid this I would advice students to go further out to the peripherally
based hospitals. A friend and I even went to non Imperial hospitals where we knew F1s who were Imperial
graduates who directed us to patients with good signs.
In the week leading up to each PACES, I partnered up with a close friend and spent a great deal of time
practising examinations and questioning. This was very helpful as it identified gaps in our knowledge and
coerced us to develop better structures to our answers.

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Presenting Images and Instruments - some examples

IMAGES
Presentation of an abdominal radiograph
There are only a few likely abdominal x-rays you are likely to be given. These include:
Small bowel obstruction
Large bowel obstruction
Volvulus
Calcified AAA
Calcified chronic pancreatitis
Regardless of what comes up, there is a logical way of talking through it, even if you are unsure of what
the diagnosis is.
i. This is an abdominal radiograph of taken on
ii. The penetration is adequate as it is possible to see the spinus processes of the lumbar vertebrae.
iii. I can see air within both the large and small bowel owing to the presence of haustra and
valvulae comiventes respectively. The small bowel is present in the centre of the film with the
large bowel around the periphery.
iv. There is no distension as the large bowel is not greater than 6cm in diameter and the small
bowel not greater than 4cm.
v. The bony aspects of the film appear normal
vi. This appears to be a normal abdominal radiograph
Or
i. The transverse colon is greater than 7cm in diameter indicating a toxic megacolon suggestive of
a severe colitis and a risk of perforation
ii. There is a coffee bean appearance to the colon arising from the left iliac fossa/right iliac fossa
suggestive of a sigmoid/caecal volvulus which is at risk of perforation.
iii. There is an area of calcification in the distribution of the aorta/pancreas which is suggestive of
calcification within a distended and degenerative abdominal aortic aneurysm/chronic
pancreatitis.
Especially important is to have the answer to:
Q What are the most common causes of bowel obstruction
A Small bowel: Adhesions, Hernias
A Large bowel: Carcinomas, Strictures from colitis
Presentation of a double-contrast barium enema with an apple core lesion

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First, it is important to understand that a double-contrast barium enema is part of a series of films
and so it is important to see a baseline film and all the films in the sequence. A single film showing
an apple core lesion may simply be visible peristalsis on the film. Hence if a film taken a few minutes
later shows the lesion still there, then you can confidently say it pathological. A double-contrast barium
film has both barium introduced using a catheter (which may be visible on the film and should be
mentioned); and air insufflated. The purpose of this is to allow better visualisation of bowel wall.
As with any radiograph it is important to first state the patients name, age and date of radiograph. I
would then mention if you can see any catheter in situ. State which part of bowel is visible. Large
bowel is identifiable by the peripheral position and presence of haustra (partial lines across the
bowel). The sigmoid colon is the s-shape portion of bowel, the rectum the part distal to this, and the
descending colon proximal. An apple core lesion is usually easy to visualise. It demonstrates
concentric extension of tumour (like a doughnut shape) allowing only a small amount of contrast to
pass through. If you do not see it, follow the course of the barium. An apple-core lesion is
pathognomonic for cancer (typically adenocarcinoma in large bowel). However you must mention the
possibility of peristalsis (see above). The examiner may ask about how the patients may have
presented, or management of the disease. Hence whilst looking at the radiograph, it is important to
think ahead. Presentation of right and left sided cancer differs, right sided typically presenting late with
chronic anaemia and diarrhoea. Left sided tumours tend to present early with signs of obstruction and
bleeding and are commoner. You should know the Duke staging. Management is either resection (eg
hemicolectomy) or palliative.
Other than an apple-core lesion, the other common finding on a double-contrast film is
diverticulosis. These will appear as small circular out-pouchings, particularly in the region of the
sigmoid colon. Again you should understand the clinical presentation and management.

INSTRUMENTS
Common instruments you may be asked to describe and discuss
Central Venous Pressure Line (CVP)
This is a central venous pressure line with either one or three lumens. It is inserted into the superior vena
cava via either the subclavian vein or the internal jugular vein using an aseptic technique. Its main
indications are to monitor the venous pressure in acutely ill patients in order to quantify fluid balance. It can
also be used to infuse drugs that are prone to cause phlebitis in peripheral veins such as dopamine,
Amiodarone or other chemotherapeutic drugs. Sometimes it is needed for intravenous therapy when
peripheral venous access is impossible.
Complications of CVP line can be divided into two parts:
1. To do with the insertion of the CVP line include pneumothorax, air embolism, haemorrhage and
arrhythmia.
2. To do with CVP line itself include infection (which can cause sepsis)
Endotracheal Tube
"This is an example of a definitive airway. It is commonly seen inserted in an emergency situation where
other forms of airway adjuncts are not capable of maintaining the airway. It is also used to maintain an
airway in patients undergoing long operations such as an abdominal aortic aneurysm repair. It is inserted
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using a laryngoscope, passing the tube through the laryngeal folds and positioning the end of the tube in
the
carina to allow ventilation of both lungs. After inserting the tube the balloon at the end of the tube is inflated.
Complications associated with the endotracheal tube include oedema, tracheal and or oesophageal
perforation, pneumothorax."
Nasogastric Tube (Ryles)
This tube is inserted through the nose pointing towards the occiput into the stomach whilst asking the
patient to swallow. Its indication includes drainage of the stomach, such as in the drip and suck regime for
example in the management of small bowel obstruction. It can also be used for feeding and to give drugs
straight into the stomach. You can check that the tube is in the right positioning by sucking up some
stomach fluid and testing its acidity using litmus paper. You can also bubble air through the tube using a
syringe and auscultate for bubbling in the epigastric area. The most accurate test is to do a chest x-ray to
see if the radio-opaque end of the tube is in the correct place (although rarely done.)
Proctoscope
"This is used to visualise pathology in the anus and the distal end of the rectum. I have seen this being used
in the outpatient clinic setting when investigating patients complaining of bright red rectal bleeding. After
explaining the procedure and obtaining consent the patient is asked to lie in the left lateral position and per
rectal examination is first carried out. Following that a proctoscope lubricated in KY gel is inserted in the
anal passage pointing towards the patients umbilicus. It can also be used in conjunction with a shoulder
syringe to inject haemorrhoids above the dentate line with a sclerosing agent.

Editors:
Kevin O'Gallagher
List of contributors:
Edward Armstrong
Peter Milton
Hetul Shah
Jannake Sivajee
Sivatharjini Sivarajasingham

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