MRCPI Part II General Medical Clinical Examination:
I've received many emails and letters asking about the MRCPI Part II General Medical Clinical Examination tips and notes, methods of conduction, examiners, examination centers, rate of success, cases...etc.
It does not differ much from that of UK (PACES) and is composed of 2 parts: long case and short ones.
The examination is usually conducted over a 3-4 day period, according the examination center and number of candidates participating. Each day is divided into a morning group and an afternoon one (7-10 candidates in each). The 7-10 candidates are distributed into "batches" (like batch1, 2, and 3). The morning group candidates should reach the examination department (a medical ward) according to the time set by the Royal College; usually between 8 to 8:30 AM (may differ a little between centers), while the afternoon ones should be there around 11 to 11:30 AM. Don't forget to bring your RCPI examination ID card. You will find there a list, with the names and code numbers of the candidates, their examination date, time, and "batch", and examination number.
You may start with the long case or the short ones (according to your batch).
Suppose you start with the long case.
1- The long case:
You will be escorted to the patient's bed. You have 45 minutes to talk and to examine him thoroughly. You will be given a clipboard to write down your notes and findings. In addition, you must come up with a list of differential diagnosis, or if the case is clear cut, a complete diagnosis. There is bedside table provided with some medical instrument (a sphygmomanometer, ophthalmoscope, tongue depressor, torch…etc) but I would suggest using "your" own instrument (a minimum requirement is to bring a stethoscope, ophthalmoscope, and patellar hammer, but I would suggest the addition of tuning forks, tape measure, red head pin, a piece of cotton wool, and a pocket Snellen's chart; these are extremely invaluable during the short cases; note that, for example, you may be given a "strange" ophthalmoscope that you are inexperienced with!).
There is clock near the bed that will ring after 45 minutes indicating that you must stop everything, and someone will take you to sit near a room where the examiners (2 in no.) are awaiting. After a short moment of greetings, start telling the story. You should deliver the overall clinical picture in a short time, fluently, professionally with compacted sentences. Don't try to talk to much, like saying no headache, no tremor, no diplopia, no…no.. no...etc; it is a postgraduate examination! Give a provisional diagnosis, a list of differential diagnosis, and what is supposed to be done then (investigations, treatment…etc). At each step, sentence, or a phrase, they may interrupt you by asking something. Expect anything to be asked, even a mortality figure, or a result of a large clinical trial (related to your case). Regarding the ethical issue and communication skills, one of the examiners may act a patient and may ask for example to explain his hepatitis B status in the long term after being exposed to an infected patient sexually!
You have 10 minutes to express your case and 20-30 minutes of discussion. The long case has a maximum score of 6.
2- The short cases:
After that, you will be taken to a room before the short cases. The interval to start them may take an hour or two depending on the examination center. Then you will be taken to short cases. Another 2 or 3 examiners will greet you. The number of cases differs, but generally from 4-6 in numbers. Expect any combination of cases, not necessarily all systems would be met. For example, you may not face an endocrinology case or an eye fundus one; the most important 4 systems are cardiology, respiratory, abdomen, and neurology. The other 2 may be any one of these: eye, endocrinology, on spot leg case, dermatology, hand…etc. At each bed, there will be small paper demonstrating a short history and what you should do next. For example: "this young girl has double vision. Examine her", or "this old man has palpitations, assess his cardiovascular status". Sometimes the order is vague, like this one: "this middle-aged man has leg edema. Examine him and try to find out why?".
A clock will be in the hands of the examiners to ring after 30 minutes. There is no "time limit for each case" (unlike UK PACES); so you should conduct you examination rapidly, smoothly but efficiently and professionally, and your answers should be short and fluent. Don’t spend more than a few minuets at each case.
Honestly, I think this is more difficult than the UK PACES as you don’t know how much time has elapsed and how much is left! Just imagine that you are examining the 3rd case and bell rings! How much did you score! God knows! The short cases have a maximum score of 6. Combined marks of 10/12 (i.e. long + short cases) and more are required to get a pass. 9 and less is a fail. Needless to say, it is better to bring and use your own instruments, and to wear a white coat. Again, don’t forget your RCPI examination ID card. Remember, practice makes perfect.
Ryder's book is an excellent aid, and Baliga's is useful for the "discussion notes".
An example of a Mock Examination:
A- Long Case:
A 67-year-old retired sales executive who was reasonably well and fit presents with a 1-hour history of left sided weakness. The weakness was noticed after awaking in the morning as an inability to get out bed at 8:30 AM. His wife helped him to sit in bed, and called for medical help. He arrived to the A/E department after 1 hour, where he was examined by a senior house officer, undergone a battery of investigations, and accordingly he was admitted. He denies being on medications, including illicit drugs. The patient neither smokes nor drinks alcohol, nor his wife who lives with him in a 2-story house, and there is no family history of note. The patient denies any head trauma, but admits to the presence of occasional bouts of palpitations for which he is unconcerned since 3 months. No history of chronic illnesses was obtained with no past history of surgical procedures. He is right handed.
Examination reveals an old man, not in apparent distress. His blood pressure is 110/85 mmHg, with the left radial pulse being 110 beat per minute irregular in rate and volume, a respiratory rate of 16 cycles per minute. His axillary temperature is 36.7 Co. He is fully conscious and oriented with normal speech apart from slight slurring due to a problem with labial constants caused by left sided upper motor neuron facial palsy. There is left sided hemiplegia of grade 3-pyramidal type and upoging planter, with hemianesthesia and homonymous hemianopia. His precordium is unremarkable apart from rapid heart beats with variable intensity of heart sounds. Other parts of examination were unremarkable.
My provisional diagnosis is cardio-embolic ischemic stroke to the right main stem of the middle cerebral artery causing this devastating stroke in a patient with undiagnosed chronic atrial fibrialltion. However, I would like to exclude other causes having a similar clinical picture, like right sided subdural hematoma and brain tumor, by ordering brain imaging starting with brain CT scan.
The questions that might be asked: management of AF, managing him in the medical ward, long term management and prognosis, eligibility for cerebral thrombolytic therapy, role of anticoagulants in ischemic stroke, general nursing (diet, swallowing, prevention of DVT and bed sores, bowel and bladder...etc), trials of stroke, medications of AF, various drugs interactions, secondary prevention . You may be given a CT scan or an ECG to read. The examiner may act as the patient's wife and asks you to explain his long term prognosis; in addition he (she) may say that he (she) is unpleased because the CT scan result was delayed and this is the cause of not receiving rtPA.
B- Short Cases (you may have any 4-6 combinations):
1- This young lady has progressive exercise intolerance, examine her cardiovascular system (?mitral stenosis).
2- This old man has severe shortness of breath, examine his chest anteriorly (?right sided lung collapse).
3- This middle aged man has abdominal discomfort, try to know why (?massive splenomegaly).
4- Look at the hands of this old lady; come up with a differential diagnosis (bilateral hand muscles wasting-?causes).
5- Look at this old Chinese lady (having a strikingly tanned face); where would you like to examine further (?Addison's disease).
6- Have a look at both eye fundi and give a complete diagnosis (?proliferative diabetic retinopathy treated with panretinal laser therapy).
7- This young man has this skin lesion, what is it? Ask him few questions to know why? (?erythema nodosum-?causes).
Note that stations 2 and 4 in the UK counterpart are covered in the long case.
I can assure 100% that if you are "well-prepared" then you will pass from the first trial! Note that the failure rate from the first attempt is high, simply because of lack preparation and unfamiliarity with examination's "environment"; a common "belief" is that the examiners are tough and trying to fail every one or the RCPI is looking at high standers! No; many candidates simply fail to impress their examiners, or to conduct the examination efficiently. Being well-informed in theory and written books does not mean that you are clinically efficient! Another thing is that many failed candidates say that this or that examination center is a disaster or tries to fail everyone or has poker-faced examiners…etc. Again, lack of preparation explains the end point.
Hope that these notes are useful. Good luck to all future MRCPI candidates.
Dr. Osama S. M. Amin MBChB MRCPI
