Surviving Part V PDF [PDF]

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SURVIVING PART V INTRO First things first: you’ve got this far which means you can go the whole way. Fifth year is going to be a taxing year, it’s going to take a lot out of you and that’s exactly why you need to start off on the right foot. A little bit of positive thinking will go a long way. There will be many times when you will wonder if it is all worth it and whether you will make it in the end and that’s perfectly normal. There will be moments of doubt, frustration and despair. That’s also normal and has a lot to do with the fact that you’ve been getting an average of three hours’ sleep every night (not including sleep during lectures). The main message is that this will be a tough year but it doesn’t mean it can’t be an enjoyable one, with the right attitude.



THE WARDS Spend time on the wards. It’s expected and it definitely helps. It’s a mistake to think that you could be using your time better sitting in your room poring over Kumar and Clarke. Having said that, make sure the time you spend on the ward is targeted. Examine patients whenever you can, aim to clerk as many as you can. In most things you will have to work as a team but when it comes to having enough patients to present or doing procedures you will have to fight to get your fair share. Discuss cases whenever you can. You might think that to have organized discussion groups after hours ‘when you have all read up on the cases’ is the best option but there really isn’t enough time. Part V is all about using opportunities as they present themselves. Discuss with your ward group the cases you have on the wards. You might not know very much at all but whatever you discuss will make it that much easier when you try and recall information or when you later go and read up on the topic. The same is true in the clinics; even if you are not being burnt by the reg or consultant, burn each other. You will thank each other in the end. Lastly, make yourself visible, to the consultant but also to the registrars. The consultant will often refer to the registrars when doing your assessments. Also, if you’ve made the consultant your friend, things will go a lot better for you come the end of the year when you need someone to vouch for you. If the consultant is around, and even if they are not, make sure you are presenting cases. There’s no better way to prepare for long cases and to make yourself visible.



READING MATERIAL It is probably true that Part V is a lot about finding a text (or a few texts) that work for you and sticking to that. If you jump around too much, it can feel a little overwhelming. Ask around from early in your rotation to see which texts other guys are using and try and decide which works best for you. It’s a bummer to find the text that you like best when you’ve got a week left in that rotation



Here is a list of texts that had a wide degree of popularity and are a pretty ‘safe’ selection. Those who are aiming high may need other material such as journals etc SURGERY There are obviously hundreds of textbooks out there and they are all helpful. This is a list of the ones used by most students or recommended by the department or just very useful, easy to read texts.       



SRB Manipal Manual of Surgery (good chapter on anaesthetics especially) Browse’s Intro to Investigation and Management of Surgical Conditions Browse’s Intro to Signs and Symptoms of Surgical Disease Lecture notes series: ENT, Neuro and Opthalmology Essential Neurosurgery Apley’s System of Orthopaedics and Fractures



Good summary/revision books:      



Andre Tan’s Surgical Notes Long cases in General Surgery Apley’s and Solomon’s (mini Apley’s) Core ENT lecture notes (a UCT chm file) MCQs and EMQs in Surgery – Bailey and Love And of course: ChiGidza



Then look around for videos, especially examination videos. There’s a really good set of Indian videos that explain in detail examination of ulcers, PVD, inguinoscrotal swellings, thyroid etc - ie all the typical short case stuff. A note about surgery: There is a HUGE amount to cover and you simply don’t have time to cover it all. The MCQ is pretty much 50% ortho and gen surg so focus your energy on these areas. After all, these are the areas you will most need as a JD or GMO. For the smaller subjects, try and balance your time. For example there is no point reading ENT or Optha in detail unless of course you are considering a career in this direction. There will be 5 or even less questions in the MCQ on each of these smaller topics and whilst it is possible to get a long case in these subjects, the chances are quite low and you will probably be forgiven for not knowing them as well as a gen surg or neuro case for example. You will probably find that you are spending a lot of time reading surgery compared to your other subjects. That’s normal but try and keep a balance as much as possible. A lot will depend on which rotation you started with and which information you need to keep refreshing yourself with. The disadvantage as you will realise is that unlike Paeds and OBG you won’t have weekly tutorials to keep the data fresh. Your best plan is to focus on the common conditions and you can be guided here by the surgery tutorials. For example, it would be unwise to read up retinal detachment or macular degeneration without having a good idea about



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eye trauma, OSSN, cataracts, glaucoma etc. Surgical emergencies are also high yield especially in ENT. Probably the best thing you can do for yourself is make sure you attend all surgery tutorials, go for calls and be on the wards. The material you learn here is relevant to our setting and will be exactly where the MCQs will be drawn from, as well as giving you the necessary exposure to pass the clinicals. MEDICINE There are really not many texts here. You can honestly do well with the Oxford Handbook and Macloed’s as your everyday reference texts But to be complete:  



Kumar and Clarke or Davidson’s (for explanation and detail) Macloed’s Clinical Diagnosis, Clinical Examination and Clinical OSCEs (3 separate books – all quite helpful)



Useful summary texts:       



Oxford handbook Aids to Undergraduate Medicine Lecture notes in Clinical Medicine 250 cases in Clinical Medicine Medicine – all time summary Short Cases in Clinical Medicine – a must have textbook for preparing for short cases 500 Single best answers in Medicine - the MCQ is almost entirely clinical vignettes so get lots of practice with questions of this style. The library has other similar texts.



The Medicine exams are HIGHLY clinical. It’s impossible to over-emphasise just how important it is to be present for ward rounds, to clerk and present patients and examine hundreds of patients (it’s about how many murmurs you’ve heard, not about spending an hour on one patient arguing over whether it’s a thrusting or a heaving apex). As it stands, the short cases in Medicine are actually worth more than the long cases. Add to that the fact that the MCQs are all about clinical reasoning, which you don’t get from a textbook but from listening to and participating in ward discussions. On top of all of that, even the data interpretation is best answered when you have been on the ward, practiced reading ECGs, chest Xrays, identified clinical signs – rashes, nail changes, eye changes etc. Try and right short notes on each case you clerk and examine. That will make it much easier to internalize information and also revise at the end of the year. Be proactive in chasing down the cases that you haven’t clerked and read up on, even if it is a patient that has been clerked already. Most of what you remember when it really counts is from the patients you have talked to, examined and followed up on the ward, not from a textbook or journal, written about patients in another country with a different set of resources and different approach to management. The patients you clerk are the exact patients that come in the exam. In terms of the long cases, as a general rule if you take a good history that is logical, if your examination is methodical and thorough, you come up with a reasonable differential that you can support and you are confident then you have everything you need to pass, even if you are a little unsure about the condition itself. You will be surprised at how much acquired knowledge you pick up, and



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reasoning skills, so that without even having read a condition in detail, you will be able to formulate a few differentials and a reasonable plan for investigation and immediate management and that is all that really matters at our level. That’s the beauty of medicine – sadly the same is not true for surgery! And make time to go to the clinical meetings. They will really help your reasoning skills and hearing how the registrars answer questions and arrive at a particular conclusion. Don’t under-estimate these meetings. They are prepared with students in mind. PAEDIATRICS Here again, there is no magic formula. You have to convince the examiner that you have spent time on the wards, you know how to handle cranky kids and you’ve been examining them. Paeds is a lot of repetition. There is a lot to read but then there are conditions that keep repeating themselves. You’ll know this from 4th year. In the exam there will not be that many surprises. Most people will get malnutrition in some shape or form, a pneumonia or chronic cough, a CP or Down’s. For the long cases they like you to have an immediate management plan and a long term plan, which involves more of the child health, social issues at home, continued nutrition, vaccination, attention to hygiene, adjustments that need to be made at school, if the child has heart failure etc. They want to see that you have considered these aspects not only the immediate medical management. The short cases too are relatively predictable and here again it’s just about how many similar cases you have seen and examined and whether you can draw the parallels. There is no secret about the texts either. The exam is taken from Coovadia and the blue book. And that’s pretty much all you need. Nelson’s is a good book if you want a little more detail and it’s packaged nicely too (like lots of colour, pictures and tables :D ) There is also a summarized Nelson’s which is great for example if you want to read hematological malignancies in 10 minutes to get a quick overview. The essay paper is mostly predictable although they can bring anything, such as the neglected tropical diseases. So start collecting documents early and start reading through them. Make yourself very familiar with the vaccination schedule and the different types of vaccines used etc. OBS AND GYNAE This is probably the most straight-forward subject in Part V. But don’t take anything for granted. Some examiners will make you sweat to prove how much you know. It’s possibly one of the smallest subjects in terms of content. The same rules apply: master the common conditions first. There is not that much to read compared to the other subjects so you have the advantage of being able to read a topic several times until you know it really well. The tutorials will also help you to keep reading throughout the year and maintain balance. Once again, part of the long case involves a clinical examination of the patient. It’s ridiculously easy to score high marks especially on the Obstetric exam so it’s worth making sure you are completely comfortable with this. For the gynae exam spend time on call to get lots of experience passing speculums (or speculae???!!). The weighting of the exams is fairly even so try and balance theory and clinical work. In terms of texts, Ten Teachers is perfectly fine for grasping basic concepts. There are hundreds of other texts available and it just depends which you prefer. Uptodate is a great reference especially for OBG where they are always asking about the best current practice so if you can



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get the downloaded version that makes it much easier otherwise the online version will obviously give you the latest info. GENERAL ADVICE Down time is important. It’s a grueling year and you need some time to get away from everything and give yourself a break. Otherwise the end of the year will come and you will have burnout. Try as much as possible to get enough sleep. It sounds unreasonable given the workload but you will find that the less sleep you get, the less information you retain. Med school as you’ve probably realized is about making the best use of the time you have. It’s not about how many hours of work you put in but what you do with those hours to maximize the amount of information you retain. Make time for prayer (if that’s something you believe in, and even if it’s not, make time for yourself to reflect on where you are in your life and what you can be to the person next to you). For those who believe in God, you will know that there is nothing you can achieve without his grace. Remember that, and remember also that through his grace all things are possible and that he has a plan for your life and will make all things work according to his purpose. So it’s only fair to spend time in his presence and to put all your trust in him and his promises.



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APPENDIX



PART V: Major topics for each subject DISCLAIMER: not intended as a complete list!! Some topics will have been left out here and there. This is only a guide. Topics are in no particular order. Most of these are fairly major topics to know for the wards, the theory papers and the long cases. What has not been included is what will be needed for short cases, examinations on the wards etc It would be impossible to cover all these topics in detail but they are all fairly high yield so it would be a good idea to know something about each.



OBs and Gynae: basically every topic in a standard OBG text! OBSTETRICS              



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Antenatal assessment Physiological changes in pregnancy Complications of pregnancy per trimester PIH Normal and abnormal fetal development Oligo/Polyhydramnios SGA/IUGR and differentiate the two APH Normal labour and the partogram Complications of labour Instrumental delivery Malpositions/malpresentations Breech delivery External cephalic version



                             



Induction of labour Normal intrapartum management Caesarian Section PPH Multiple Pregnancies Twin to twin transfusion syndrome Puerperal Sepsis PMTCT Anemia in pregnancy Maternal comorbid disease in pregnancy The fetal skull Vertically transmitted infections Diabetes in pregnancy Gestational diabetes Perinatal mortality Preterm labour PROM/PPROM UTI in pregnancy HIV in pregnancy Prenatal screening VBAC Antihypertensive pharmacology in preg Theories of pre-eclampsia APS Analgesia in Labour Cord emergencies Fetal distress Intrauterine fetal death Post term pregnancy Shoulder dystocia



GYNAE      



Miscarriages Ectopic pregnancies MVA Cervical Ca Ca Cervix screening methods in detail HPV + vaginal, vulval Ca - the basics



                            



Normal menstrual cycle Disorders of the menstrual cycle Amenorrhea approach and management Contraception in detail Ultrasonography in obs and gynae PID Vaginal infections/discharge Infections of upper female genital tract Fibroid uterus Myomectomy VVF The menopause (climacteric) Ovarian cysts Ovarian malignancies PCOS Endometrial hyperplasia/malignancy Endometrial ablation HIV in gynae Subfertility and fertility techniques Laparoscopy in gynae AUB Dysmennhorea Hysteroscopy GTD Pelvic Organ Prolapse Endometriosis/adenomyosis Bartholin’s cyst Atrophic vaginitis Postmenopausal bleeding



SURGERY GEN SURG General:      



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Ulcers Hernias Snake Bites Skin grafts Burns Breast – common benign disease and Ca



            



Diabetic Foot Wounds and healing Surgical site infections Surgical nutrition Management of pain in surgical patients The thyroid Soft tissue sarcomas Stomas Fistulae PVD Amputations Melanoma Complications of prolonged bed rest



Abdo:                   



Obstructive Jaundice Cholecystitis Pancreatitis Gallstones Cholangiocarcinoma Portal Hypertension Acute abdomen Abdominal compartment sydrome Abdominal trauma – blunt and sharp Malignancies: esophagus, stomach, pancreas, colon, rectal and anal Perianal disease – fissures, haemorrhoids Inflammatory bowel disease Irritable bowel syndrome Appendicitis Volvulus Diverticular disease Haemorrhoids, anal fissures, perianal abscesses Liver malignancies Intestinal obstruction



ORTHO



OPTHA



             



               



Principles of fractures Metabolic bone diseases Osteomylitis Bone tumours Paget’s disease Orthopaedic trauma – ABCs Osteoarthritis Traction systems Compartment syndrome Club foot Leg-Calve Perthe’s disease Slipped Upper Femoral Epiphysis Fat embolism syndrome Fractures/displacement of o Forearm o Elbow o Supracondylar region o clavicle o Shoulder o Spine o Pelvis o acetabulum o Head of femur o Neck of femur o Shaft of femur o Patella o Tib/fib o Ankle o Calcaneum



ENT           



CARDIO         



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Empyema thoracis Chest trauma Pneumothorax Pulmonary contusion Chest drains Surgical conditions of the esophagus Lung malignancies Aneurysmal disease Malignant pleural effusions



Cataracts Glaucoma Ocular trauma Destructive eye surgery The red eye The pupil The watery eye Diabetes and the eye Ptosis Proptosis Squint Retinal detachment Eyelid disease – common conditions Corneal scar OSSN Refractive errors







Rhinosinusitis Deep spaces of the neck Retropharyngeal abscess Peritonsillar abscess Epistaxis Middle ear infections Cholesteatoma Hearing deficits Examination of ENT Tracheo(s)tomy Head and neck tumours esp nasopharyngeal Ca and laryngeal ca Laryngeal polyps



MAXILLO   



Le fort fractures Swollen jaw differentials Dentistry topics



NEURO               



PAEDS SURG Headache Spinal shock Spinal cord injury Spina bifida Ct scans, MRI, C-spine Xrays Hydrocephalus congenital and acquired Raised ICP Head injury Intracranial tumours TB spine Neuropathies Cauda equine/conus medullaris Neurocysticercosis Intracranial bleeds Intracranial abscesses – pott’s puffy tumour



URO                      



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Prostate Ca BPH Renal stones Bladder Ca Prostatitis TURP syndrome Cryptorchidism Circumcision Phimosis/paraphimosis Urogenital trauma Bladder outlet obstruction Hematuria Scrotal swellings Fournier’s gangrene UTI Urogenital manifestations of Schisto Renal Cell carcinoma Penile Ca Urinary diversion Testicular tumours Neurogenic bladder VUR



        



Intussusception Congenital urological conditions Hirschsprung’s Wilm’s tumour Retinoblastoma Biliary atresia Imperforate Anus Pyloric stenosis Gastroschisis/omphalocele



MEDICINE CVS:            



Heart Failure ACS Angina Hypertension ECG interpretation Endocarditis RHD Pericardial Disease Myocardial Disease Arrythmias – esp AF Valvular Heart Disease DVT



Resp:         



The pneumonias (bact/fungal/viral/protozoal) Pulmonary Embolism Pleural effusions Interpretation of CXRs Asthma Bronchiectasis COPD/Emphysema Lung function tests (the basics) Lung Ca



  



Respiratory Failure Cor Pulmonale Obstructive Sleep Apnea



Immunology: 



HIV







o 2016 Guidelines o ART Pharmacology o Treatment Failure Autoimmune disease: SLE, Sarcoidosis, AI hepatitis, APS Kaposi Sarcoma Tuberculosis



Neuro:           



Meningitis Stroke and intracranial bleeds GBS Transverse myelitis Motor Neuron Disease Headaches Movement disorders – the basics Epilepsy HIV neuropathy Mono/Polyneuropathies – the basics Hepatic Encephalopathy



Renal:         



 



AKI CKD UTI Neprotic syndrome Glomerulonephritides Renal replacement therapy TIN ATN Renal manifestations of systemic disease: HIV, DM, HTN, Tenofovir toxicity Hepatorenal syndrome HUS/TTP



Endocrine:        



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Hyper/hypothyroidism Thyroid neoplasms DM DI Pituitary Disorders Hypo/Hyperadrenalism Parathyroid disease Endocrine sexual/hormonal imbalance



  Gastro:            



Peptic, duodenal ulcers H Pylori Dysphagia and alarm symptoms GI bleeding Cirrhosis Chronic Liver Disease Hepatic malignancies Portal Hypertension Ascites Drug induced liver disease Diarrhoea – acute vs chronic and classifying causes of chronic Inflammatory bowel disease



Rheumatology:      



Gout Rheumatoid arthritis Osteoarthritis Reactive/septic arthritis Ankylosing spondylitis Dermatomyositis



Hematology:      



Anemias Hemolytic disease Thalassemias Approach to bleeding Coagulation disorders Anticoagulants pharmacology



 



Haematological malignancies – the basics Interpretation of blood panel/peripheral smear



Infectious diseases:          



Malaria Common OIs : crypto, candida, toxo PCP Viral Hepatitis STIs: diagnosis and management Common G+ and G- infections Cholera Typhoid Schistosomiasis Intestinal parasites



Clinical Chem:  



Interpretation of common lab results Urinalysis – how to do it and what each parameter means



Misc:  



Organophosphate poisoning Paracetamol/aspirin poisoning



ALL the common medical emergencies – PASS/FAIL material! See Oxford Handbook



PAEDIATRICS Most of the topics for Medicine are repeated for Paeds. Special emphasis should be given to the following topics though: CVS: 



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Congenital heart disease: cyanotic and acyanotic



    



Acquired heart disease Pediatric stroke syndromes IE RF/RHD Heart Failure



NEURO:      



Growth and Development Meningitis: pathogens and presentation at each agegroup TB meningitis Cerebral Palsy Seizural Disorders – a basic overview Hydrocephalus



Resp:        



Pneumonia URTI Croup Epiglotitis Laryngotracheomalacia Bronchiolitis Cong lung disease Upper airway obstruction



GIT:    



Malnutrition – know this BACKWARDS – 75% of all long cases BF/infant-child nutrition Jaundice – all ages Acute diarrhoea/dysentery and common pathogens



Hematology:    



Fanconi’s anemia SCD Thalassemias Bleeding disorders – approach to a bleeding child



Endocrine: 



CAH and adrenal crisis



Renal:     



Post-strep GN Nephrotic syndrome Urinalysis! Wilm’s tumour HUS



     



CHILD HEALTH 



Immunology:    



Allergies Asthma Cong immune deficiencies Common skin conditions



Neonatology:         



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Care of the newborn Normal newborn assessment Neonatal resus Neonatal sepsis HIE Kernicterus Hypernatremic dehydration Fluid and electrolyte balance Meconium Aspiration Syndrome



Bronchopulmonary Dysplasia Necrotising enterocolitis Neural tube defects Periventricular haemorrhage Respiratory distress syndrome Transient tachypnea of the newborn



        



EPI, vaccination schedule and everything about each individual vaccine – look for WHO position papers Neonatal/infant/U5/Child mortality – causes and prevention Notifiable diseases Outbreak investigation and management MDGs/SDGs Child abuse PMTCT Global and national child health programs Neglected tropical diseases Oncology and Palliative care – the basics