How to PASS Internal Medicine Semester 6 (to those who go to the same Uni as I do)

Please note "HOW TO PASS". I have Passed the posting, but not in flying colours... but I have also gone into the exam without any preparatory reading of any sorts, just did what I could - which turned out to be slightly different from others.

in my opinion, when people are asked how were the exams (in effort to know how they may survive it through when it is their turn), people often say "Its not difficult" or worse still "Okay." - which isn't helping at all.

so I hope this helps.

the End Of Posting Exam for semester 6 Internal Medicine for the time being, is One long case.

we are allowed a certain amount of time (I had 2 hours in total - for complete clerking of patient) with the actual patient, following which we will be assessed by the examiner. those are the components the examiner may mark us on;

• History taking skills
• Physical Examination skills
• Clinical Reasoning and Differential Diagnosis
• suggestion of Provisional Diagnosis with Justifications
• Investigations and Justifications
• Non-Pharmacological Management and counselling (if applicable)
• a "touch" of Management.

I have to stress that the Long Case Presentation is highly subjective, and the examiner need not follow a strict marking criteria to mark the students... and the difficulty of the exam may vary, according to the patients.

History taking

In clinical school, Not only we are required to know how to take a complete history, we will need to take what is called a "Focused History" - where we may need to focus on several aspects of the history, which will vary from patient to patient. this may be very difficult for some of us who thought a complete history will help us with diagnose and manage a patient - not only our history must be complete, it must be proving and detailed enough to know the patient in deeper level.

for example, in Asthmatic patients, it is important to ask about...

• severity of the asthma - and control
• can s/he talk in full sentences during attack?
• how long is each asthma attack?
• how frequent is it?
• how many sick leaves does s/he have to take per week/month due to the asthma?
• what medication is s/he currently on, and how compliant is s/he? does the medication work?
• any blue discoloration of nails / lips seen by a bystander during attack? (cyanosis)
• does the patient monitor the Peak Flow Rate? 
• was s/he explained of how to use a Metered Dose Inhaler?

and so forth...

How do we study that? 

One may realize that knowing what to ask in every single disease is Near-Impossible. 

Yes, it may be impossible to know what history to illicit in every disease known to man in our level of experience - however, we will be exposed to the real cases in the Hospital at our posting, and through everyday observation, we will be able to pick out what are the common cases we see in the Medical Ward. If in doubt, we may keep a record of the patients that we have seen throughout our posting - and study the most common ones first. 

Our Best Bet, is that we will get the common ones. if not, maybe you should start charity work (to increase your good karma - just kidding)

I personally found the exam passable, thanks to the every morning rounds the MOs / Specialists do in the Hospital - they will question the HOs during the rounds regarding the investigations, management and history of patient, and those are the questions that the examiners may look for during Exams.

Physical Examination

the "focused" nature of the patient assessment also applies to the Physical Exam. 

each examiner may prefer different techniques - just like how we were puzzled at how we were told to do different things by different lecturers. 

But as long as we always have a Reason behind doing everything, they will not be disappointed. the worst thing we can do is do things because "Prof. XXX said so", or "because I read in Mc'XXX that this is the correct method". Always tell them why you do things your way. sometimes you are completely wrong, but they will correct you if you are.

Suggestion of Diagnoses

Now, We are expected to provide at least several DDs, and support our diagnosis.

a through understanding of the pathophysiology of the symptoms and signs may help us provide a logical explanation to our suggestion of diagnosis. the Differential Diagnosis must start from the moment you ask the first question to the patient - hence during the history taking.

for example, when you have a patient who has a Jaundice, with Fever for 3 days - you will be interested in knowing...

1. is this a medical / surgical Jaundice? (any YES in the questions below will increase the suspicion for surgical Jaundice)
1. ask if there is any pale stool / discoloration of urine
2. ask for pain in the abdomen
3. ask for any itchiness of skin
4. ask for change in bowel habits
2. ask about the risk factors
1. any contact with fresh water / jungle trekking? (checking for leptospirosis - which is quite common in our local setting)
2. any ingestion of seafood (commonly shell-fish) that may have caused this? (Hepatitis A?)
3. Sexual history, sharing of needles, history of surgery in the past, any risky behaviours (hepatitis B, or C)
4. Alcoholism, Medication history (Metabolic Liver disease, Hepatotoxicity of drugs)

through asking those questions above, you would get a rough Idea of the provisional Diagnosis.

the Provisional Diagnosis must be comfirmed with the investigations that you are going to suggest.

Also, you will need to "rule out" several of your differential diagnosis by several more investigations.

Investigation and Justifications

the investigations you suggest must have good justifications. each useless investigation is money, resource and time wasted.

also, the justification given must be specific enough to be convincing. for e.g. - when you have patient with Breathlessness for 1 week

FBC - to see the blood picture 

Peak Flow Meter - to rule out Asthma

X-ray

Echo

CT scan

is not specific enough, although it is not incorrect. - it doesn't show what you know.

FBC - to rule out bacterial infection (look at neutrophil count, if bacterial, Neutrophil - high), also to look for anemia (anemia may cause breathlessness)

Peak Flow Meter - in Obstructive Airway Disease, the Peak Expiratory Flow Rate will be lowered more than 75% blah blah

Chest X-ray - to see any signs of Lung Carcinoma (Cannonball lesions), to see Radiological signs of lobar Pneumonia , to see any signs of lung collapse, pneumothorax, hydrothorax, Pulmonary embolism which all may cause breathlessness

Echocardiogram - to assess the left ventricular function / ejection fraction, to rule out any valvular defects which may cause low output heart failure. 

these, may sound better. (although I'm not 100% sure if above are correct. I call it sophisticated confabulation - crudely put, Smart Bullshit)

How Do I Prepare for this thing?

I suggest not only you INPUT (e.g. Reading books, following rounds, and talking to patients) you may want to practice how to OUTPUT (discuss cases with collegues, present cases to lecturers, write a blogpost on how to pass exams).

From what I see, most medical students are professional at Input - they read well, but there is some kind of obstruction in the output - causing a constipation of knowledge. if your verbal flow is not good, the lecturer may put an enema into it - causing some verbal diarrhea - which may prove unpleasant. 

a good balance of input and output practice is important to ensure good flow of communication during exam.