M2 SUPER PREP 2013 9 OCTOBER 2013

ALEXANDRA YUNG | KENNEDY NG | NIGEL FONG

OVERVIEW OF SESSION Objective: To provide guidance in Coping with M2 – academically and nonacademically

Using the M2 year well to prepare for M3 and beyond

Basic history taking skills - to set the framework for studying M2 content.

COPING WITH MEDICAL SCHOOL

KENNEDY NG

HOW WOULD YOU DESCRIBE YEAR 2 IN A FEW WORDS?

WHAT’S YEAR 2 IS LIKE? •  It’s Content Heavy •  It’s FAST •  It’s Super Important (sets a solid foundation for Year 3) •  It’s FUN •  It brings a whole lot of responsibilities

SCOPE Overview of Year 2

•  Schedule •  Examinations •  Topics

7 Habits of Highly Effective Medical Students

Other issues

•  CG Formation •  Research •  Others

OVERVIEW OF YEAR 2

OVERVIEW OF YEAR 2 •  >10 subjects, tested in… •  4 examinations – CA1, CA2, Pros and CSFP •  Over 7 months of Lectures, 1 month of Clinical Posting

and of course.. •  3 months Holiday (you will never get this again) ;P

OVERVIEW OF YEAR 2

Start of Year 2

CA1 (11 Nov)

•  13 weeks of lectures

•  1 week of break

CA2 (20, 21 Jan)

•  5 weeks of lectures

•  5 weeks of break

Pros (13,14 Mar)

•  4 weeks of lectures

•  4 weeks of break

CSFP (17 Apr)

•  1 week of Procedural Skill

•  1 month of Clinical Posting

TOPICS (CONTENT-WISE) •  From heaviest to lightest

•  Systemic Pathology •  Systemic Pharmacology •  Microbiology •  Neuroscience •  Immunology •  Aging •  General Pathology / General Pharmacology •  Medicine and Society •  Ethics •  Genetics •  Information Literature

TOPICS (BY SEMESTER) •  Before CA1

•  Genetics •  Information Literature •  Immunology •  Microbiology •  General Pharmacology and Pathology

•  Before CA2 •  Systemic Pharmacology and Pathology

•  Before Professional Exam •  Systemic Pharmacology and Pathology •  Aging •  Neuroscience

TOPICS (BY SEMESTER) •  Throughout the year

•  Medicine and Society/Ethics •  CSFP

7 HABITS OF HIGHLY EFFECTIVE MEDICAL STUDENTS

1. HAVE FAITH IN YOURSELF •  Thousands and thousands of medical students have

passed Year 2. You will not be the exception. •  Top 2 reasons for failing:

•  Lack of time management •  Over-commitment to activities

•  Now that you know the reasons, AVOID THEM.

WHAT IS THE SOURCE OF COMPETITIVENESS IN

MEDICINE?

2. BE SECURE IN YOURSELF

Your worth as a person is not tied to your achievements.

You are uniquely and wonderfully made. No

one can become like you.

2. BE SECURE IN YOURSELF •  When you are secure in yourself, you are striving to

become better, not to beat someone, but to be the best you can be.

•  And.. You will not be afraid to help someone reach their fullest potential even if it means them becoming better than you.

3. HAVE THE LONG TERM PERSPECTIVE OF THINGS •  Why are you studying so hard for?

•  To be better than others, to score higher than others? Or to be a good doctor?

•  Do I study only for those things that are tested? •  Do I have the medical student-mentality or doctor-

mentality?

•  On the hand…

3. HAVE THE LONG TERM PERSPECTIVE OF THINGS •  Are you taking your work seriously? •  Are you skipping lectures and tutorials and are never in

school? •  Are you taking your friends for granted?

4. BEING CONSISTENT AND PLAN AHEAD •  Year 2 is fast - when you start to lag, you lag like crazy

•  Strive to finish the week’s worth of lecture by the end of every week.

•  Have you consciously thought through your commitment levels? •  Do the high key period of your various activities overlap? •  Strive to DECONFLICT them.

5. PRIORITIZE IMPORTANT THINGS IN YOUR LIFE What are the top 5 regrets of dying people? [By Bronnie Ware] •  I wish I’d had the courage to live a life true to myself, not the

life others expected of me

•  I wish I hadn’t worked so hard •  I wish I’d had the courage to express my feelings •  I wish I had stayed in touch with my friends •  I wish that I had let myself be happier

6. LOVE ONE ANOTHER AND HELP EACH OTHER Learn to see this community as an extension of your own body. This way, it might be easier to learn to care for one another.

You need one another next time!

6. LOVE ONE ANOTHER AND HELP EACH OTHER •  Create an accepting and celebratory culture •  Share and help each other in studies, research, and all the

good stuff ;)

7. STUDY SMART AND HARD •  Listen attentively to Nigel and Alex later! =)

OTHER ISSUES CLOSE TO HEART

CG FORMATION Reminiscing Childhood in Medical School

CG FORMATION It can get ugly.

But it need not be.

CG FORMATION •  Some guidelines: •  Strive to be the perfect group member and not to find the

perfect group (…there’s no such thing as a perfect group) •  Open Communication is essential. •  Be a man / woman of your word. •  You do not need to do with your best friends or girlfriends/

boyfriends – it can work both way. •  Keep a lookout for the quieter people in your batch! •  Don’t take things personally.

Are you Mr. Kiasu?

RESEARCH

COMMON QUESTIONS Should I do Research? Will I lose out if I don’t do it?

When should I do Research? What are the types of research I can do?

How do I start! Where to find lobang???

SHOULD I DO? •  It’s an essential skill – part of the many hats doctors wear. [What are

these hats] •  It is part of the curriculum in Year 4 and the school’s dream is for

every YLL student to present at an international conference once •  Possible reasons for doing:

•  Genuine Interest [Story of Jack Andraka] •  To hone your skills and gain experience •  To establish good working relationships with mentors •  To improve your CV

•  The above reasons are all legitimate reasons, but in everything you are doing: •  Do it with the right attitude •  Do it with your best ability

SHOULD I DO? •  Having said that, is it essential that I must be doing a

project to get into residency? •  Will be helpful, but it’s not the only way.

WHAT THEN IS THE RIGHT ATTITUDE?

WHEN SHOULD I START? •  It’s really up to you. •  A few question to ask:

•  Do I have an interest? •  Do I have the time? •  Am I willing to commit?

•  The trade off as you progress through Medical School •  Lower M – Less Knowledge, More Time •  Upper M – More Knowledge, Less Time

WHAT ARE THE TYPES OF RESEARCH? •  Wet Lab and Dry Lab

•  Wet Lab – Laboratory work •  Dry Lab – Analysis of Data

•  Ask Gerald Sng (Research Directorate) =)

LOBANGS LOBANGS EVERYWHERE

Research Projects >>>>>> Students

Don’t rush!

HOW DO I START? •  Again… Ask your friendly research directorate.

•  Make them work! Haha.. •  Ask your friendly seniors •  Ask your friendly friends (I hope!) •  Look out for good mentors (Lecturers, Clinical Tutors, etc)

•  Student-orientated – Nurturing, Teaches •  High Quality Research •  Similar Interest as you •  Chemistry

BEING AN EXAMPLE

SERVANT LEADERSHIP •  You guys are Year 2s and will start taking up a lot of

responsibilities and leadership. •  There are juniors under you who will be looking up to you

guys! =) •  Teach them, guide them and help them! Pass down the

goodness. •  Help those who are struggling with their examinations and

with school.

SUMMARY

USING THE M2 YEAR WELL TO PREPARE FOR M3 AND BEYOND

NIGEL FONG

A PATIENT’S JOURNEY Returned from 2-week holiday in China. Present to GP clinic with 3 day history of sniffling and shortness of breath

What can you, as a doctor, do for her?

A PATIENT’S JOURNEY Mdm SKO took a course of antibiotics but reported no improvement 1 week later – presents to A&E with sudden inability to pass urine for 12 hours

What can you, as a doctor, do for her?

A PATIENT’S JOURNEY On history, she reports loss of weight and loss of appetite over the past 6 months. You examine her and find abdominal swelling You order Chest X ray and CT abdomen/pelvis

CT abdomen & pelvis: “ureteric obstruction secondary to diffuse peritoneal masses”

A PATIENT’S JOURNEY

What can you, as a doctor, do for her?

http://radiology.casereports.net/index.php/rcr/article/viewArticle/152/559

A PATIENT’S JOURNEY “My mum went into A&E because she couldn’t pass urine. The doctor came out and his first words were ‘the cancer is very bad’. Our reply was ‘I think you’ve got the wrong set of relatives’ “

“The Doctor explained that cervical cancer was sexually transmitted. I feel terrible and very dirty – is it my fault that my wife has to get cancer?” Why her?

A PATIENT’S JOURNEY Biopsy performed Diagnosis: stage 4 cervical cancer with lung and peritoneal metastases “Doctor, how long do I have to live?”

“Doctor, I don’t want to die. My daughter is getting married and I want to be there”

What can you, as a doctor, offer her?

A PATIENT’S JOURNEY Patient and family keen for chemotherapy. But patient is not fit for chemotherapy and deteriorating very rapidly Patient very breathless, O2 levels dropping

“Doctor, are you going to put her on a ventilator?”

What can you, as a doctor, offer her?

WHAT YOU LEARN NOW Example: Myocardial Infarction Epidemiology

Normal anatomy & physiology

Pathology – gross and microscopic

Pathophysiology

Clinical presentation

Complications

Pharmacology

IN CLINICAL PRACTICE… Example: Myocardial Infarction Presentation: “Doctor, my chest pain” History

Examination

Investigations

Management

•  Acute vs follow-up •  Pharmacological vs non pharmacological

Diagnosis & Differential diagnosis

Confirm diagnosis, rule out Ddx

Diagnosis & Differential diagnosis

IN CLINICAL PRACTICE… What are the causes of chest pain? What do I need to consider in particular for this patient? How do I tell the causes of chest pain apart?

•  On history •  On examination: what to look out for? •  What investigations to order and how to interpret?

Metabolic   Respiratory  CO2  reten)on  

Central  

Peripheral  

Measure  anion  gap  

Normal  

↓  HCO3-‐   ↑  CO2  

High  AG  met  acidosis  

Uremic  acidosis  

Lac)c    acidosis  

Diabe)c    ketoacidosis  

Exogenous  

High  

Normal  AG  met  acidosis  

↓  HCO3-‐   ↑  H+  

•  Renal  tubular  acidosis  

GIT  -‐  Diarrhoea  -‐  Ileostomy  -‐  Uretosigmoid          fistula  

Renal  -‐  Acetazolamide  -‐  HyperPTH  -‐  Tubular  damage        (drugs,  heavy  metals)  -‐  Hyperkalemia  

ACIDOSIS

WHAT YOU LEARN NOW Example: Pneumonia Epidemiology

Microbiology – what bugs

Pharmacology – how to treat

Complications

IN CLINICAL PRACTICE… Example: Pneumonia Presentation: 80y lady with fever and SOB History

Examination

Investigations

•  Blood tests •  Imaging

Management

Diagnosis & Differential diagnosis

Confirm diagnosis, rule out Ddx

Diagnosis & Differential diagnosis

IN CLINICAL PRACTICE… 90y / Male / Chinese Presenting complaint: Fall at home. Past Medical History:

•  Leukemia •  Hepatitis B •  Subdural haemorrhage •  Atrial fibrillation

Why did he fall?

What are the medical problems that need to be addressed in this patient?

IN CLINICAL PRACTICE…

IN CLINICAL PRACTICE… What we learn traditionally: One patient, one disease. One disease, one presentation.

In actual clinical practice: •  Multiple pathologies, multifactorial presentations •  Disease-disease interactions •  Disease-environment interactions •  Drug-disease interactions •  Drug-drug interactions •  Also have to communicate well, deal with socioeconomic

issues, relatives, ethical dilemmas…

HOW TO APPROACH M2 M2 is a critical foundation for subsequent years. Do not study simply for exams, but study to prepare yourself for future clinical practice.

•  Go for clinical significance •  Do not ‘mug, vomit, and forget’. Understand and remember –

you will need this knowledge for years. •  Draw connections between the various subjects •  Exams are moving away from recall qns, to integration &

clinically-focused questions. •  Do not ignore things that not immediately tested e.g. CSFP

lectures, ethics.

COMMON ISSUES FACED Typical illustrative problems

There are too many bacteria to memorize These drugs have so many funny side effects that do not make sense I study hard but nothing stays

COPING WITH THE CONTENT “There are too many microorganisms to memorize” Classify the microorganisms

•  By characteristics (gram + vs – vs does not stain) •  By disease caused (causes of pneumonia: community vs

hospital-acquired, broncho- vs lobar-, etc)

Think of a patient. “A patient comes in with new onset pneumonia. What empirical antibiotic would you give? Why?”

Focus on things that are common and things that are dangerous

COPING WITH THE CONTENT “These drugs have so many funny side effects that do not make sense” Link to mechanism, physiology: why does the drug cause this side effect? Work it out step by step. Do not hesitate to revisit M1 content.

Focus on things that are common and things that are dangerous

Explain it to yourself and others. If you can understand, you do not need to memorize. Study in groups and test each other.

Think of a patient: if you give this drug, what do you need to look out for and why?

COPING WITH THE CONTENT “I study hard but nothing stays” Revise soon and often.

Find something interesting about what you study.

Active vs passive knowledge – how do you make the knowledge yours?

•  Digest what you read not simply sift through •  Summarize ± make notes (but don’t overdo) •  Classification schemes: e.g. “The causes of respiratory tract

infection include…” •  Compare and contrast: e.g. B cells vs T cells •  Make links

COPING WITH THE CONTENT Making links is important Back to front:

•  Normal function •  Pathology •  Presentation •  Management including

pharmacology

•  Front to back: • Presentation • Pathology • Management including

pharmacology Bonus: • Other differentials •  Investigations

COPING WITH THE CONTENT !

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CLOSING POINTERS You are in this for the long haul – pace yourself

The first step to being a good doctor is to be a decent human being

Do not underestimate the importance of what you learn

Know what you are studying, why you are studying, and how you are studying it.

Never do things just for the sake of doing something.

Take care of yourself and each other. All the best!

HISTORY TAKING

ALEXANDRA YUNG

HISTORY TAKING

What do you understand by the term “history taking”?

THIS IS BOB. HE’S HAVING CHEST PAIN.

You are the doctor on-call. What will you do next?

HISTORY TAKING Is a focus-directed, purposeful, information-gathering process Which aims to arrive at a diagnosis or establish the possible differential diagnoses And thus is a structured process that requires thought and organisation

MEDICAL HISTORY 90% of the diagnosis Provides context Without context, you only have random facts and no leads.

BEWARE

The gap between medical terminology and layman lingo

PATHOLOGICAL VS CLINICAL

Disease Complaint 2

Complaint 1

Complaint 3

Patient’s Complaint

PATHOLOGICAL VS CLINICAL

Disease 1

Disease 2

Disease 3

Patient’s Complaint

More Specific

Complaint

SO IN ORDER TO FIND WHAT YOU SEEK…

You must know what you’re looking for

LET’S TRY AGAIN! WITH NEW INFO. AMI Unstable

Angina PT PE Aortic

Dissection OR

Ischaemic Chest Pain • Prolonged, central, crushing chest pain • of acute onset • radiating to the arm/neck/jaw/epigastrium, • worse on exertion, • alleviated by rest/GTN

•  Sharp chest pain •  Of sudden onset •  A/w dyspnoea •  Trauma Hx

•  Sharp chest pain •  of sudden onset •  a/w acute dyspnoea, giddiness •  Hx of PVD/ immobility/long flight/ recent op

•  Very sudden onset of anterior chest pain •  Radiating to interscapular region/back •  “tearing/shearing” pain •  Collapse

•  Severe chest pain •  A/w forceful vomiting/retching

BOB HAS CHEST PAIN.

You are the doctor on-call. What will you do next?

WHAT TO LOOK FOR

Personal Details Name, I/C, age, gender, race, premorbid

functional status

History of Presenting Complaint Pain, dyspnoea, etc.

Past Medical/Surgical History Past stroke, MI, DM, HTN, HLD, Recent

op, etc.

Systemic Review Check other systems

Drug History Drug allergy, current medication

Family History DM, HTN, IHD, HLD, AI conditions, etc.

Social History Occupation, diet, physical activity,

smoking, alcohol, caregiver, environment Patient’s Concerns

TAKE HOME POINTS History taking is a focus-directed, purposeful, information-gathering process in which the aim is to arrive at a diagnosis or possible differential diagnoses. It is a structured process that requires thought & organisation. History taking is an information gathering process – if you don’t understand enough, find out more. But to find what you seek, you must first know what you’re looking for! Common things first. Focus on the important! Have an approach – studying effectively thus means figuring out the system, i.e. finding a way that can help you think about and process the information being thrown at you.