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Swachchhanda Songmen

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  • Had slide number 41 been number 42,it would have been the answer to universe and all.Nevertheless very informative and helpful as I myself am a final year student.Thanks a lot.God bless you.(I'm an atheist though)
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  1. 1. FINAL YEAR- overview BY SENIORS
  2. 2. <ul><li>All the slides of the presentation are based on the experience of 24 th batch, any deviations from these facts would be circumstantial; however any resemblance will be savoured. </li></ul>
  3. 3. What r we expected? <ul><li>Junior internship </li></ul><ul><li>Internal assessments </li></ul><ul><li>Final examination theory practicals </li></ul>
  4. 4. Junior internship <ul><li>Postings </li></ul><ul><li>Self study </li></ul><ul><li>Classes </li></ul><ul><li>(anesthesiology) </li></ul>
  5. 5. No time to waste
  6. 6. postings <ul><li>Attendance -is must except radiology </li></ul><ul><li>Punctuality- on or in time but not late </li></ul><ul><li>Know ur cases n what u r supposed to do </li></ul><ul><li>Ask questions but not with empty mind to teachers </li></ul><ul><li>Note the favourite topics and questions and replies, esp. morning conferences, GR </li></ul>
  7. 7. <ul><li>Try to answer the teachers </li></ul><ul><li>No extra works e.g. always dressings </li></ul><ul><li>Study charts, investigation forms, normal values e.g. biochemistry, FP devices </li></ul><ul><li>Practise examination long cases esp. ENT short cases </li></ul>
  8. 8. <ul><li>Discussion among frens ; only most important topics ; tell listen make them understand; don’t waste time, energy in non-imp topics </li></ul><ul><li>Don’t compare ur knowledge with ur peers </li></ul><ul><li>Not only theoretical topics but clinical examination be discussed n practice as well; use standard book as reference; </li></ul><ul><li>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? </li></ul>
  9. 9. <ul><li>SHARE WHAT U KNOW </li></ul><ul><li>LEARN WHAT U DONT </li></ul>
  10. 10. Comprehensive - Its ur life, make it large. <ul><li>Make the steps habit rather than rot memory so it comes naturally; try to be comprehensive as possible e.g. </li></ul><ul><li>Show me knee reflex: small things matter greatly </li></ul><ul><li>What u going to do? </li></ul>
  11. 11. <ul><li>Stand on right side of patient </li></ul><ul><li>Greet n tell pt what r u going to do- hammer doesn’t hurt </li></ul><ul><li>Ask consent n cooperation </li></ul><ul><li>Expose the body part with muscle e.g. knee reflex </li></ul><ul><li>Joint in mid-range of movement </li></ul><ul><li>Hammer type </li></ul><ul><li>The way I strike with hammer i.e. just release, </li></ul>
  12. 12. <ul><li>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 </li></ul><ul><li>Perform both sides </li></ul><ul><li>Try to remember grading of reflex (not mandatory) </li></ul><ul><li>Beware of pitfalls; some common are: </li></ul>
  13. 13. <ul><li>Look for the muscle contraction instead of the movement of the joint (usually mistake in knee reflex) </li></ul><ul><li>Hit at the tendon not the muscle coz muscle contraction may occur even if tendon reflex absent if hit directly on muscle belly </li></ul>
  14. 14. <ul><li>Arrange n attend classes (middle of postings n before assessments) of </li></ul><ul><li>X-rays esp. medicine, surgery, ENT, ortho </li></ul><ul><li>Instruments- wards, OT </li></ul><ul><li>Important procedures as chest tube; tapping; </li></ul><ul><li>Can carry cardex know diseasewise drug n their doses </li></ul>
  15. 15. Visit presentations- do not go unprepared <ul><li>Know presentation topics in morning n visit if topic pertinent n of ur standard; eg thyroid examination by residents was good </li></ul><ul><li>Surgery third yr GR very useful- try to help the juniors; study about the topic well; note questions n answers n teachers </li></ul>
  16. 16. Group discussion in Postings
  17. 17. Self study <ul><li>No stress </li></ul><ul><li>Time mgm is life mgm </li></ul><ul><li>Adequate rest, diet </li></ul><ul><li>Stm stipulated time not enough but can be covered later on on other postings or assessments e.g. pediatrics, medicine </li></ul><ul><li>Regularity continuity devotion </li></ul>
  18. 18. <ul><li>Perfection is unachievable yet we need to strive for it in life……………………………….. </li></ul><ul><li>Why? Are we pigheaded? Are we dogs? </li></ul>
  19. 19. Because life is a journey not a destination.
  20. 20. notes <ul><li>Class notes- Prof. Raut, Sayami, Khakurel , PRS, ENT </li></ul><ul><li>Self notes- imp. Topics 2-3 books, others one textbook </li></ul><ul><li>Know topics- must, better, nice to know </li></ul><ul><li>How?- past questions, postings, seniors, cases </li></ul><ul><li>No notes needed for ENT; add more information on the respective pages; some throat sections </li></ul><ul><li>Underlining wont pay much; no time later on for revision; time will be crucial later on </li></ul>
  21. 21. How to prepare best notes? <ul><li>Only for most imp. Topics </li></ul><ul><li>Various sources- books, classnotes, discussions at postings with residents practical tips, teachers </li></ul><ul><li>Format for answers (in note; or at least in mind): for theory, practicals n real life as well </li></ul><ul><li>Later if vague questions, don’t haste; if 10 mins allocated, 28 think-write rule rather than 82 write-repent rule </li></ul>
  22. 22. E.g. clinical features of Acute Myocardial Infarction <ul><li>Pain- SOCRATES </li></ul><ul><li>SOB, NV, fear, anxiety </li></ul><ul><li>Tissue damage- fever </li></ul><ul><li>Impaired myocardial fn- low BP, raised JVP, S3, lung crepitations, cold periphery, oliguria </li></ul><ul><li>Sympathetic stimulation- HTN, tachycardia, sweating, pallor (ant. Wall MI) </li></ul><ul><li>Parasympathetic stimulation- vomiting, bradycardia (inf. Wall MI) </li></ul><ul><li>Complications- MR, VSD </li></ul><ul><li>Any comorbidities </li></ul><ul><li>Any trauma or etiologies ppting AMI </li></ul>
  23. 23. Presentations-history <ul><li>include all the heads n subheads e.g. even informant n reliability, religion, occupation, menstrual Hx (LMP must) </li></ul><ul><li>Specific instructions e.g. Prof. Khakurel don’t call a child a patient </li></ul><ul><li>Admitted …. Days back (rather than date) from ER/ward for </li></ul><ul><li>HOPI: </li></ul><ul><li>Explore symptomatology (system, disease) </li></ul><ul><li>Etiology, severity or stage, complications, risk factors, rule out D/D, comorbidities, systemic review </li></ul>
  24. 24. Diagnosis- comprehensive <ul><li>Disease, etiology, severity, complications, comorbidities ; e.g. </li></ul><ul><li>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 </li></ul><ul><li>No abbreviations as much as possible e.g. not COPD but chronic obstructive pulmonary disease </li></ul><ul><li>Do not get the side wrong </li></ul><ul><li>Specifically distinct for Gyne/Obs </li></ul>
  25. 25. Management( =investigation+ treatment) e.g. Investigations of Acute Pancreatitis <ul><li>1. Diagnostic USG, CT scan, serum amylase, serum lipase, abdominal X-rays </li></ul><ul><li>2. Supportive </li></ul><ul><li>Severity (for RANSON or other indices)- WBC, glucose, LDH, AST, BUN, ABG, Ca, electrolytes </li></ul><ul><li>etiology - LFT, USG, ERCP, PTC, PTH, Ca, </li></ul><ul><li>Complications - CXR, CT, ECG, albumin, Hct, </li></ul><ul><li>Comorbidity - diabetes, HTN </li></ul><ul><li>Rule out d/d of acute abdomen a/t age sex (listed in chapter of acute appendicitis)- </li></ul><ul><li>Routine - Hb, urine RE/ ME </li></ul>
  26. 26. Investigation findings e.g. CXR findings of Mitral Stenosis <ul><li>f/o LA enlargement- </li></ul><ul><ul><li>Mitralisation of left heart border- small aortic knuckle, convexity d/t dilated pulm A, prominent LA appendage, left border of LV </li></ul></ul><ul><ul><li>Splaying of carina </li></ul></ul><ul><ul><li>Double contour of rt heart border </li></ul></ul><ul><li>f/o Pulmonary edema- upper lobe blood diversion, kerley B line, batwing appearance, cardiomegaly, pleural effusion </li></ul><ul><li>f/o Pulmonary HTN- peripheral pruning, dilated prox. Pulm A with tapered end, RAH, RVH </li></ul><ul><li>f/o calcified mitra valve </li></ul>
  27. 27. e.g. Treatment of enteric fever <ul><li>Definitive: Tab cipro 500 mg PO BD for 14 days (dose details); in children chloramphenicol </li></ul><ul><li>Supportive: nursing; nutrition (no dietary restriction); antipyretics; fluid & electrolytes; correct anemia </li></ul><ul><li>Complications: hmg, perforation, etc. mgm of enteric encephalopathy high dose dexamethasone </li></ul><ul><li>Treatment of carrier: cipro; ampi; cholecystectomy </li></ul><ul><li>Prevention (if time permits): 3 vaccines </li></ul>
  28. 28. TAKE <ul><li>CLASSIFY </li></ul>
  29. 29. What to do at radio? <ul><li>Study medicine/surgery </li></ul><ul><li>Visit one unit a day know basics about </li></ul><ul><li>X-rays , </li></ul><ul><li>USG, </li></ul><ul><li>CT especially head injury, </li></ul><ul><li>special investigations e.g. IVU , cholangiogram, mammogram, HSG, etc </li></ul>
  30. 30. What to do at Emergency? <ul><li>Ample of opportunities </li></ul><ul><li>Safety comes first </li></ul><ul><li>Take few cases u can handle n follow up. not load oneself with many cases at a time </li></ul><ul><li>Try iv cannulation, blood drawing, NG tubing, ABG, LP, suturing, catheterisation </li></ul><ul><li>Carry GPA sir’s book/ oxford </li></ul><ul><li>Take care of ur goods they may walk away e.g. book, steth </li></ul><ul><li>Don’t hesitate to ask ur seniors e.g. interns </li></ul>
  32. 32. AND OUR ER? <ul><li>Don’t know exactly the data…sorry </li></ul><ul><li>But no complacency. </li></ul><ul><li>Incidences of accidental pricks </li></ul><ul><li>Iv cannulation……one incident </li></ul><ul><li>Drawing blood sample…….one incident </li></ul><ul><li>Suturing…………..one incident </li></ul><ul><li>Injecting local anesthesia……….one incident </li></ul><ul><li>Do u want to be a part of similar anecdote? </li></ul>
  33. 33. why are we worried? <ul><li>Each exposure is an urgent health issue for the exposed person </li></ul>
  34. 34. How does it occur commonly? <ul><li>Percutaneous injury, usually inflicted by a hollow-bore needle, most common mechanism </li></ul><ul><li>percutaneous exposure to HIV-infected blood: 0.3% (95% CI: 0.2-0.5) </li></ul><ul><li>mucous-membrane exposure: 0.09% (95% CI:0.006-0.5) </li></ul><ul><li>transmission risk increased if: </li></ul><ul><li>device causing the injury visibly contaminated with blood, </li></ul><ul><li>device used for insertion into a vein or artery </li></ul><ul><li>the device caused a deep injury </li></ul>
  35. 35. How to prevent? <ul><li>Vaccination against hepatitis B virus </li></ul><ul><li>Universal precautions </li></ul>
  36. 36. Universal precautions <ul><li>CDC: a set of precautions designed to prevent transmission of HIV, HBV, and other blood-borne pathogens when providing first aid or health care. </li></ul><ul><li>Applicable to: </li></ul><ul><li>blood, </li></ul><ul><li>other body fluids containing visible blood, </li></ul><ul><li>semen, and vaginal secretions. </li></ul><ul><li>tissues and </li></ul><ul><li>fluids: cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids </li></ul>
  37. 37. <ul><li>Not applicable to </li></ul><ul><li>feces, </li></ul><ul><li>urine, </li></ul><ul><li>sweat, tears, </li></ul><ul><li>nasal secretions, </li></ul><ul><li>Human breast milk, </li></ul><ul><li>sputum and vomitus unless they contain visible blood. </li></ul><ul><li>saliva except when visibly contaminated with blood or in the dental setting where blood contamination of saliva is predictable </li></ul>
  38. 38. What to do? <ul><li>don gloves on. </li></ul><ul><li>Gloves be changed after contact with each patient. </li></ul><ul><li>Hands and other skin surfaces should be washed immediately if contaminated with blood or body fluids requiring universal precautions. </li></ul>
  39. 39. <ul><li>Wear Face masks </li></ul><ul><li>Wear protective eyewear; so lucky people have glasses on </li></ul><ul><li>Wear apron </li></ul><ul><li>Careful during procedures………..practical tips at bedside, orientations and classes </li></ul>
  40. 40. Postexposure prophylaxis <ul><li>Has finally found its place in noticeboard after accident </li></ul><ul><li>Dont’s: squeeze </li></ul><ul><li>Do’s: wash with soap and running water </li></ul><ul><li>Contact duty officer and follow instructions as the notice in the board. </li></ul>
  41. 41. <ul><li>点击缩略图或者视频名称可以直接观看视频。 点击所属分类分类中的标签可以直接搜索该标签相关的视频。 点击“收藏视频”可以将您喜爱的视频收藏到收藏夹中。 点击“获得链接”可以得到该视频的原始链接、论坛发布链接等。 </li></ul>And…………… at times
  42. 42. MARATHON
  43. 43. After jr. internship b4 assessments
  44. 45. Internal assessments <ul><li>Enlighten urself with knowledge </li></ul>
  45. 46. Lot of time to study lots of books
  46. 47. <ul><li>Warm up for the grand finale </li></ul><ul><li>E.g. </li></ul><ul><li>Prepare materials to study in finals </li></ul>
  47. 48. 20% of total marks <ul><li>Theory- all except internal medicine (Prof. JPA planning from ur batch) </li></ul><ul><li>At basic science </li></ul><ul><li>Don’t cheat (strict, no adv, can ask fren) e.g. </li></ul><ul><li>One fren in gyne </li></ul><ul><li>Practical- medicine, gyne, pediatrics </li></ul><ul><li>OSCE in gyne, peda ( write it down early coz they recur in final OSCE ) </li></ul>
  48. 49. Clinical examination-practice
  49. 50. <ul><li>Before assessment- medicine only </li></ul><ul><li>Systems- neuro, respi, GI, CVS </li></ul><ul><li>Get urself ready with all necessary kits </li></ul><ul><li>Divide topics among frens and practice in group on frens </li></ul><ul><li>Before finals- all subjects </li></ul><ul><li>Standard books- macleod, hutchison’s </li></ul>
  50. 51. <ul><li>Most imp time- most fruitful, u think u now know a lot </li></ul><ul><li>Cool, a bit of apprehension is good </li></ul><ul><li>Adequate time for study </li></ul><ul><li>All will pass; even some fail once, reexam very soon e.g. gyne-next day, ophthalmo- no reexam </li></ul>
  51. 52. <ul><li>95% ur hand </li></ul><ul><li>Rest in </li></ul>
  52. 53. Now n then stealing beautiful moments- oranges
  53. 54. FINAL <ul><li>DO OR DIE </li></ul><ul><li>NO COMPROMISE </li></ul><ul><li>OR U WILL REPENT </li></ul><ul><li>LEAVE NO STONE UNTURNED </li></ul><ul><li>TAKE RISKS BUT CALCULATE BEFOREHAND </li></ul>
  54. 55. THEORY 8 papers how to prepare? <ul><li>Before exam: </li></ul><ul><li>Know probable questions- different techniques </li></ul>
  55. 56. <ul><li>Time constraints </li></ul><ul><li>Only revise important topics </li></ul><ul><li>Be armed to the teeth e.g. knowledge, admit card, stapler, ballpens, scale, pencils, eraser, sharpner </li></ul>
  56. 57. Exam hall- what to do now? <ul><li>Read questions carefully- carefully- carefully- medicine complications ?TOF; question papers prone to error so clarify </li></ul><ul><li>No panicking if u don’t know the answer if not heard e.g. Noonan’s syndrome </li></ul><ul><li>Answer orderly (examiner point of view)- can write PTO if paper not filled in the end </li></ul><ul><li>or </li></ul><ul><li>Write the best answer first with diagrams n illustrations if possible e.g.Davidson’s </li></ul>
  57. 58. <ul><li>Write first page slowly with good handwriting(1 st impression is the last impression) </li></ul><ul><li>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 </li></ul><ul><li>Diagram if possible </li></ul>
  58. 59. practicals <ul><li>12 exams </li></ul><ul><li>3 blocks 4 exams in each block </li></ul><ul><li>2-3 days gap in each block </li></ul>
  59. 60. <ul><li>Easier </li></ul><ul><li>Teachers helpful </li></ul><ul><li>Cool </li></ul><ul><li>Follow instructions </li></ul><ul><li>Minors don’t usually fail if u do major good </li></ul><ul><li>Be ready with summary and comprehensive diagnosis </li></ul>
  60. 61. Internal medicine <ul><li>Long case; Short case </li></ul><ul><li>For cases; </li></ul><ul><li>Fully equipped e.g. neuro kit </li></ul><ul><li>Findings ask seniors on morning note ( not urself, not admission note ) </li></ul><ul><li>Time mgm (don’t know when they turn up) </li></ul><ul><li>Less- so imp. Hx n exam to be done </li></ul><ul><li>More- comprehensive diagnosis n summary , few more details, possible questions </li></ul><ul><li>Formal clean attire </li></ul><ul><li>No duel; “sorry” “I don’t know” “I am confused sir” </li></ul>
  61. 62. <ul><li>OSCE (no revision class; u l know at exam hall or outside somehow; 20 spots: xrays, ECG, ABG, cases) </li></ul><ul><li>Vivas- easy; same questions in a day so ask previous frens against rules </li></ul>
  62. 63. psychiatry <ul><li>Long case n viva-format imp </li></ul><ul><li>Don’t worry; residents helpful </li></ul><ul><li>Nice experience </li></ul><ul><li>Format </li></ul><ul><li>Depends on teacher </li></ul>
  63. 64. dermatology <ul><li>OSCE n viva </li></ul><ul><li>Easier </li></ul><ul><li>Revise limited imp topics </li></ul><ul><li>Later students know cases but use what is between ur ears e.g. leprosy and bullous pemphigoid </li></ul>
  64. 65. surgery <ul><li>Long case </li></ul><ul><li>Short cases- 4 ( 7mins each short time)- challenging </li></ul><ul><li>OSCE (15 questions, revision classes imp., no chance of cheating) </li></ul><ul><li>Vivas-3 </li></ul>
  65. 66. Short case e.g. inguinoscrotal swelling hernia or hydrocele <ul><li>Hx- occupation ; swelling- onset, progression ( reducibility ), duration </li></ul><ul><li>If hernia i.e. reducible- irreducible, pain, fever </li></ul><ul><li>If hydrocele i.e. trauma, pain, loss of testicular sensation </li></ul><ul><li>Examination- </li></ul><ul><li>Inspection: site, no, shape, size, extent , skin overlying </li></ul><ul><li>Palpation: pain, temp, no, shape, size, surface, </li></ul><ul><li>get over swelling, expansile cough impulse ; </li></ul><ul><li>hernia: ring occlusion test after pt. reduces himself; hydrocele: fluctuation, transillumination </li></ul><ul><li>Supine while pt himself reduces; test on standing position </li></ul>
  66. 67. orthopedics <ul><li>OSCE- 5 questions along with surgery OSCE </li></ul><ul><li>Case- easy </li></ul>
  67. 68. anesthesia <ul><li>Only vivas </li></ul><ul><li>Drugs, instruments </li></ul><ul><li>Same questions for the day so later students are lucky to know the pet questions </li></ul>
  68. 69. dental <ul><li>No spotting this time n last time </li></ul><ul><li>Only long case </li></ul><ul><li>Instruments </li></ul><ul><li>Easy- follow format </li></ul><ul><li>Depends on teacher </li></ul>
  69. 70. Gyne/ Obs <ul><li>Long case- </li></ul><ul><li>format imp. </li></ul><ul><li>Short case </li></ul><ul><li>OSCE- 20 questions, revision class ,no cheating, easy </li></ul><ul><li>vivas-2 superclassic topics e.g.FP,CS </li></ul><ul><li>No failure; all pass </li></ul><ul><li>Take books- read ur case until teachers turn up </li></ul>
  70. 71. pediatrics <ul><li>Long case </li></ul><ul><li>Short cases- 2 (one neonate very imp ) </li></ul><ul><li>Vivas- cool (from PRS book) </li></ul><ul><li>No hanky panky; follow instructions strictly </li></ul><ul><li>No need to be afraid of stern teachers </li></ul><ul><li>PRS sir’s book n handouts is a must </li></ul>
  71. 72. eye <ul><li>Long case- ward usu </li></ul><ul><li>Short case- OPD </li></ul><ul><li>OSCE- 5; very easy coz help available </li></ul>
  72. 73. ENT <ul><li>Best exam system – very difficult to fail </li></ul><ul><li>Long case- 30 </li></ul><ul><li>Short cases- 10,10 </li></ul><ul><li>OSCE- 10 </li></ul><ul><li>Viva-40 (ear- 1Q, nose- 1Q, throat- 1Q, xray- 1Q, procedure- 1Q, instrument- 1Q) from Prof Shrivastav’s book mostly </li></ul><ul><li>Don’t quote Dhingra as source </li></ul>
  73. 74. Community medicine <ul><li>Prepare report as soon as possible now in Jr. internship </li></ul><ul><li>Unscientific evaluation </li></ul><ul><li>Don’t confront at table at individual level; later whole batch can talk to HOD </li></ul><ul><li>Be open tell what u know </li></ul>
  74. 75. Practical tips <ul><li>Class by interns very very effective e.g.by Dr. Naresh, Nabaraj, Madan </li></ul><ul><li>Discussion important topics every night in small circle of frens e.g. </li></ul>
  75. 76. Very imp materials <ul><li>Notes: undoubtedly </li></ul><ul><li>Exam Format: Piryani’s </li></ul><ul><li>Medicine review: Rumi 25 th batch </li></ul><ul><li>OSCE solved: esp for gyne peda and others </li></ul><ul><li>Drug dosage chart </li></ul><ul><li>Ur kits for practical exams e.g. neuro kit, measuring tape, growth chart </li></ul>
  76. 77. e.g. books n topics <ul><li>Any textbook but prepare notes in copy </li></ul><ul><li>K & C- arrhythmias </li></ul><ul><li>ECG made easy </li></ul><ul><li>Neurology- stroke/ parkinsonism/ multiple sclerosis/ approaches e.g. peripheral neuropathy </li></ul><ul><li>Harrison’s- coronary artery disease/ infective endocarditis/ epilepsy </li></ul><ul><li>Kundu- for revision, in beginning don’t waste much time; short cases; very impractical theoretical points e.g. breath sounds </li></ul><ul><li>NTC manual- few pages </li></ul>
  77. 78. Contd.. <ul><li>Medicine </li></ul><ul><li>Prof. Raut’s note </li></ul><ul><li>Prof. Arun Sayami (if he returns to department) </li></ul><ul><li>Surgery examination videos </li></ul><ul><li>Growth chart </li></ul><ul><li>Nutritive value of common food </li></ul><ul><li>Prof. PRS handouts (respi, GI, probable questions) </li></ul><ul><li>Forceps, and delivery videos by Rumi and Sagar. </li></ul>
  78. 79. <ul><li>Best of luck </li></ul>
  79. 80. At the end, rejoice
  80. 81. Have a blast !!!!!!!!!!!!!!!!!!!