FINAL YEAR- overview

BY SENIORS

All the slides of the presentation are based on the experience of 24th batch, any deviations from these

facts would be circumstantial; however any resemblance will be

savoured.

What r we expected?

Junior internship Internal assessments Final examination theory practicals

Junior internship

Postings Self study Classes

(anesthesiology)

No time to waste

postings

Attendance-is must except radiology Punctuality- on or in time but not late Know ur cases n what u r supposed to do Ask questions but not with empty mind to

teachers Note the favourite topics and questions and

replies, esp. morning conferences, GR

Try to answer the teachers No extra works e.g. always dressings Study charts, investigation forms, normal

values e.g. biochemistry, FP devices Practise examination long cases esp. ENT

short cases

Discussion among frens ; only most important topics; tell listen make them understand; don’t waste time, energy in non-imp topics

Don’t compare ur knowledge with ur peers Not only theoretical topics but clinical examination

be discussed n practice as well; use standard book as reference;

Ask any queries to seniors; don’t feel awkward; they had been through the same phase e.g. even mitral valve is on right or left side?

SHARE WHAT U KNOW

LEARN WHAT U DONT

Comprehensive- Its ur life, make it large.

Make the steps habit rather than rot memory so it comes naturally; try to be comprehensive as possible e.g.

Show me knee reflex: small things matter greatly

What u going to do?

Stand on right side of patient Greet n tell pt what r u going to do- hammer doesn’t hurt Ask consent n cooperation Expose the body part with muscle e.g. knee reflex Joint in mid-range of movement Hammer type The way I strike with hammer i.e. just release,

If u can’t elicit, Jendrassick (reinforcement) maneuver before u say reflex is absent- proper technique; just before striking as effect lasts a few seconds

Perform both sides Try to remember grading of reflex (not

mandatory) Beware of pitfalls; some common are:

Look for the muscle contraction instead of the movement of the joint (usually mistake in knee reflex)

Hit at the tendon not the muscle coz muscle contraction may occur even if tendon reflex absent if hit directly on muscle belly

Arrange n attend classes (middle of postings n before assessments) of

1. X-rays esp. medicine, surgery, ENT, ortho

2. Instruments- wards, OT

3. Important procedures as chest tube; tapping; • Can carry cardex know diseasewise drug n

their doses

Visit presentations- do not go unprepared

Know presentation topics in morning n visit if topic pertinent n of ur standard; eg thyroid examination by residents was good

Surgery third yr GR very useful- try to help the juniors; study about the topic well; note questions n answers n teachers

Group discussion in Postings

Self study

No stress Time mgm is life mgm Adequate rest, diet Stm stipulated time not enough but can be

covered later on on other postings or assessments e.g. pediatrics, medicine

Regularity continuity devotion

Perfection is unachievable yet we need to strive for it in life………………………………..

Why? Are we pigheaded? Are we dogs?

Because life is a journey not a destination.

notes

Class notes- Prof. Raut, Sayami, Khakurel, PRS, ENT

Self notes- imp. Topics 2-3 books, others one textbook

Know topics- must, better, nice to know How?- past questions, postings, seniors, cases No notes needed for ENT; add more information on

the respective pages; some throat sections Underlining wont pay much; no time later on for

revision; time will be crucial later on

How to prepare best notes?

Only for most imp. Topics Various sources- books, classnotes,

discussions at postings with residents practical tips, teachers

Format for answers (in note; or at least in mind): for theory, practicals n real life as well

Later if vague questions, don’t haste; if 10 mins allocated, 28 think-write rule rather than 82 write-repent rule

E.g. clinical features of Acute Myocardial Infarction

Pain- SOCRATES SOB, NV, fear, anxiety Tissue damage- fever Impaired myocardial fn- low BP, raised JVP, S3, lung

crepitations, cold periphery, oliguria Sympathetic stimulation- HTN, tachycardia, sweating,

pallor (ant. Wall MI) Parasympathetic stimulation- vomiting, bradycardia (inf.

Wall MI) Complications- MR, VSD Any comorbidities Any trauma or etiologies ppting AMI

Presentations-history

include all the heads n subheads e.g. even informant n reliability, religion, occupation, menstrual Hx (LMP must)

Specific instructions e.g. Prof. Khakurel don’t call a child a patient

Admitted …. Days back (rather than date) from ER/ward for

HOPI: Explore symptomatology (system, disease) Etiology, severity or stage, complications, risk factors,

rule out D/D, comorbidities, systemic review

Diagnosis- comprehensive

Disease, etiology, severity, complications, comorbidities; e.g.

Left sided ischemic stroke/CVA with right sided hemiplegia with global aphasia with left sided upper motor neuron facial palsy with urinary incontinence with newly diagnosed type II diabetes mellitus with resolved sensory aphasia with newly developed constipation

No abbreviations as much as possible e.g. not COPD but chronic obstructive pulmonary disease

Do not get the side wrong Specifically distinct for Gyne/Obs

Management(=investigation+ treatment)e.g. Investigations of Acute Pancreatitis

1. Diagnostic USG, CT scan, serum amylase, serum lipase, abdominal X-rays

2. Supportive Severity (for RANSON or other indices)- WBC, glucose,

LDH, AST, BUN, ABG, Ca, electrolytes etiology- LFT, USG, ERCP, PTC, PTH, Ca, Complications- CXR, CT, ECG, albumin, Hct, Comorbidity- diabetes, HTN Rule out d/d of acute abdomen a/t age sex (listed in chapter

of acute appendicitis)- Routine- Hb, urine RE/ ME

Investigation findings e.g. CXR findings of Mitral Stenosis

f/o LA enlargement-1. Mitralisation of left heart border- small aortic knuckle,

convexity d/t dilated pulm A, prominent LA appendage, left border of LV

2. Splaying of carina3. Double contour of rt heart border

f/o Pulmonary edema- upper lobe blood diversion, kerley B line, batwing appearance, cardiomegaly, pleural effusion

f/o Pulmonary HTN- peripheral pruning, dilated prox. Pulm A with tapered end, RAH, RVH

f/o calcified mitra valve

e.g. Treatment of enteric fever

Definitive: Tab cipro 500 mg PO BD for 14 days (dose details); in children chloramphenicol

Supportive: nursing; nutrition (no dietary restriction); antipyretics; fluid & electrolytes; correct anemia

Complications: hmg, perforation, etc. mgm of enteric encephalopathy high dose dexamethasone

Treatment of carrier: cipro; ampi; cholecystectomy Prevention (if time permits): 3 vaccines

TAKE

CLASSIFY

What to do at radio?

Study medicine/surgery Visit one unit a day know basics about X-rays, USG, CT especially head injury, special investigations e.g. IVU,

cholangiogram, mammogram, HSG, etc

What to do at Emergency?

Ample of opportunities Safety comes first Take few cases u can handle n follow up. not load

oneself with many cases at a time Try iv cannulation, blood drawing, NG tubing, ABG,

LP, suturing, catheterisation Carry GPA sir’s book/ oxford Take care of ur goods they may walk away e.g.

book, steth Don’t hesitate to ask ur seniors e.g. interns

OCCUPATIONAL EXPOSURE TO BLOOD –BORNE PATHOGENS IN HEALTH CARE SETTINGS

AND OUR ER?

Don’t know exactly the data…sorry But no complacency. Incidences of accidental pricks

1. Iv cannulation……one incident

2. Drawing blood sample…….one incident

3. Suturing…………..one incident

4. Injecting local anesthesia……….one incident Do u want to be a part of similar anecdote?

why are we worried?

Each exposure is an urgent health issue for the exposed person

How does it occur commonly?

Percutaneous injury, usually inflicted by a hollow-bore needle, most common mechanism

percutaneous exposure to HIV-infected blood: 0.3% (95% CI: 0.2-0.5)

mucous-membrane exposure: 0.09% (95% CI:0.006-0.5) transmission risk increased if:1. device causing the injury visibly contaminated with blood, 2. device used for insertion into a vein or artery3. the device caused a deep injury

How to prevent?

Vaccination against hepatitis B virus Universal precautions

Universal precautions

CDC: a set of precautions designed to prevent transmission of HIV, HBV, and other blood-borne pathogens when providing first aid or health care.

Applicable to:1. blood, 2. other body fluids containing visible blood, 3. semen, and vaginal secretions. 4. tissues and 5. fluids: cerebrospinal, synovial, pleural, peritoneal,

pericardial, and amniotic fluids

Not applicable to1. feces, 2. urine, 3. sweat, tears,4. nasal secretions, 5. Human breast milk,6. sputum and vomitus unless they contain visible blood. 7. saliva except when visibly contaminated with blood or

in the dental setting where blood contamination of saliva is predictable

What to do?

don gloves on. Gloves be changed after contact with each

patient. Hands and other skin surfaces should be

washed immediately if contaminated with blood or body fluids requiring universal precautions.

Wear Face masks Wear protective eyewear; so lucky people

have glasses on Wear apron Careful during procedures………..practical

tips at bedside, orientations and classes

Postexposure prophylaxis

Has finally found its place in noticeboard after accident

Dont’s: squeeze Do’s: wash with soap and running water Contact duty officer and follow instructions as

the notice in the board.

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MARATHON

After jr. internship b4 assessments

Internal assessments Enlighten urself with knowledge

Lot of time to study lots of books

Warm up for the grand finale

E.g.

Prepare materials to study in finals

20% of total marks

Theory- all except internal medicine (Prof. JPA planning from ur batch)

At basic science

Don’t cheat (strict, no adv, can ask fren) e.g.

One fren in gyne Practical- medicine, gyne, pediatrics OSCE in gyne, peda (write it down early coz

they recur in final OSCE)

Clinical examination-practice

Before assessment- medicine only

Systems- neuro, respi, GI, CVS

Get urself ready with all necessary kits

Divide topics among frens and practice in group on frens

Before finals- all subjects Standard books- macleod, hutchison’s

Most imp time- most fruitful, u think u now know a lot

Cool, a bit of apprehension is good Adequate time for study All will pass; even some fail once, reexam

very soon e.g. gyne-next day, ophthalmo- no reexam

95% ur hand Rest in

Now n then stealing beautiful moments- oranges

FINAL

DO OR DIE NO COMPROMISE OR U WILL REPENT LEAVE NO STONE UNTURNED TAKE RISKS BUT CALCULATE

BEFOREHAND

THEORY 8 papers how to prepare?

Before exam: Know probable questions- different

techniques

Time constraints Only revise important topics Be armed to the teeth e.g. knowledge, admit

card, stapler, ballpens, scale, pencils, eraser, sharpner

Exam hall- what to do now?

Read questions carefully- carefully- carefully- medicine complications?TOF; question papers prone to error so clarify

No panicking if u don’t know the answer if not heard e.g. Noonan’s syndrome

Answer orderly (examiner point of view)- can write PTO if paper not filled in the end

or Write the best answer first with diagrams n

illustrations if possible e.g.Davidson’s

Write first page slowly with good handwriting(1st impression is the last impression)

Time mgm is life mgm (80 marks in 180 minutes or 40 marks in 90 mins so divide) i.e. 2 min for a mark then 20 mins for review or if some questions left behind

Diagram if possible

practicals

12 exams 3 blocks 4 exams in each block 2-3 days gap in each block

Easier Teachers helpful Cool Follow instructions Minors don’t usually fail if u do major good Be ready with summary and comprehensive

diagnosis

Internal medicine

Long case; Short case For cases; Fully equipped e.g. neuro kit Findings ask seniors on morning note (not urself,

not admission note) Time mgm (don’t know when they turn up) Less- so imp. Hx n exam to be done More- comprehensive diagnosis n summary, few

more details, possible questions Formal clean attire No duel; “sorry” “I don’t know” “I am confused sir”

OSCE (no revision class; u l know at exam hall or outside somehow; 20 spots: xrays, ECG, ABG, cases)

Vivas- easy; same questions in a day so ask previous frens against rules

psychiatry

Long case n viva-format imp Don’t worry; residents helpful Nice experience Format Depends on teacher

dermatology

OSCE n viva Easier Revise limited imp topics Later students know cases but use what is

between ur ears e.g. leprosy and bullous pemphigoid

surgery

Long case Short cases- 4 (7mins each short time)-

challenging OSCE (15 questions, revision classes imp.,

no chance of cheating) Vivas-3

Short case e.g. inguinoscrotal swellinghernia or hydrocele

Hx- occupation; swelling- onset, progression (reducibility), duration

If hernia i.e. reducible- irreducible, pain, fever If hydrocele i.e. trauma, pain, loss of testicular sensation Examination- Inspection: site, no, shape, size, extent, skin overlying Palpation: pain, temp, no, shape, size, surface, get over swelling, expansile cough impulse; hernia: ring occlusion test after pt. reduces himself;

hydrocele: fluctuation, transillumination Supine while pt himself reduces; test on standing

position

orthopedics

OSCE- 5 questions along with surgery OSCE Case- easy

anesthesia

Only vivas Drugs, instruments Same questions for the day so later students

are lucky to know the pet questions

dental

No spotting this time n last time Only long case Instruments Easy- follow format Depends on teacher

Gyne/ Obs

Long case-

format imp. Short case OSCE- 20 questions, revision class ,no cheating,

easy vivas-2 superclassic topics e.g.FP,CS No failure; all pass Take books- read ur case until teachers turn up

pediatrics

Long case Short cases- 2 (one neonate very imp) Vivas- cool (from PRS book) No hanky panky; follow instructions strictly No need to be afraid of stern teachers PRS sir’s book n handouts is a must

eye

Long case- ward usu Short case- OPD OSCE- 5; very easy coz help available

ENT

Best exam system – very difficult to fail Long case- 30 Short cases- 10,10 OSCE- 10 Viva-40 (ear- 1Q, nose- 1Q, throat- 1Q, xray-

1Q, procedure- 1Q, instrument- 1Q) from Prof Shrivastav’s book mostly

Don’t quote Dhingra as source

Community medicine

Prepare report as soon as possible now in Jr. internship

Unscientific evaluation Don’t confront at table at individual level;

later whole batch can talk to HOD Be open tell what u know

Practical tips

Class by interns very very effective e.g.by Dr. Naresh, Nabaraj, Madan

Discussion important topics every night in small circle of frens e.g.

Very imp materials

Notes: undoubtedly Exam Format: Piryani’s Medicine review: Rumi 25th batch OSCE solved: esp for gyne peda and others Drug dosage chart Ur kits for practical exams e.g. neuro kit,

measuring tape, growth chart

e.g. books n topics

Any textbook but prepare notes in copy K & C- arrhythmias ECG made easy Neurology- stroke/ parkinsonism/ multiple sclerosis/

approaches e.g. peripheral neuropathy Harrison’s- coronary artery disease/ infective

endocarditis/ epilepsy Kundu- for revision, in beginning don’t waste much time;

short cases; very impractical theoretical points e.g. breath sounds

NTC manual- few pages

Contd..

Medicine Prof. Raut’s note Prof. Arun Sayami (if he returns to department) Surgery examination videos Growth chart Nutritive value of common food Prof. PRS handouts (respi, GI, probable questions) Forceps, and delivery videos by Rumi and Sagar.

Best of luck

At the end, rejoice

Have a blast!!!!!!!!!!!!!!!!!!!