How to Maximize Your 3rd year

Asst/Prof Ngiam Kee Yuan

Consultant
Division of Endocrine Surgery
Department of Surgery
National University Hospital Singapore

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Top 3 questions
Feeling lost in the 3rd Year?

What is the highest yielding activity in

the 3rd year?

What is the top fact that M5s wished

they knew in M3?

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Low Yield Activities
Following the round
Studying in the library
Summarizing notes
Making and re-making notes
Turning up for more of the same tutorials
Blind leading the blind
Stressing over the residency
my friend knows more than me

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High Yield Activities

Clerking AND presenting patients (skills)

Examining patients (skill)
Bedside tutorials (skills)
Clerking and examining patients in clinics (skills)
Examining patients in day surgery (skills)
Reading on the go
Asking questions
Seeing and doing the must see and must dos

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Surgical History Presentation
40 year old Chinese Female
Significant background of gallstone disease (Sales pitch)

PC RHC pain (approaches)

HPC 3/7 progressive, colicky RHC pain severity 8/10 radiating to right
back a/w Fever Tm =39.0, NBNB vomiting x2. pain worse with oily food,
better with staying still. Had previous similar pain but now pain is
constant and worse. (Positive findings first)
NO dark urine/pale stools, pruritus, yellowing of skin (Complication of
positive finding)

NO recent hx of travel, no chills and rigors (DD1 hepatic

abscess/heaptitis)
NO diarrhoea, generalized abdominal pain, abdominal bloatedness
(DD2 diverticulitis)
NO cough, SOB, CP (DD3 right sided pneumonia)

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Surgical History Presentation
PMhx (surgery relevant hx first)
1.Biliary colic with US proven gallstones 2 years ago refused surgery
2.Previous C-section
3.HPT

Drug Hx
1.Antihypertensives
NO DRUG ALLERGIES (exam fail if not mentioned)

Social Hx
1.Married, lives with husband and child in condo
2.Financially stable, works as sales agent
3.Drinks 2 glasses of wine a week, non-smoker (must give details)

FHx
No significant hx of neoplasia or gallstone dx

Systemic enquiry is UNREMARKABLE

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Surgical History Presentation
On Examination
Patient appears flushed and dehydrated but otherwise is alert and comfortable
Drip on back of hand (general appearance first)
T=39.0, P=90, BP 126/70
Most obvious clinical sign is RHC pain, murphys sign +ve. (state +ve findings first)

Otherwise, (followed by DD exclusion and normal findings)

No jaundice
No stigmata of chronic liver disease
No generalised abdominal tenderness, rebound ve
Liver span 12cm, no hepatosplenomegaly
BS sluggish
L: clear and HS normal

In summary,(only positive findings)

Mrs XXX is a 40 yr-old chinese female who presents with a 3/7 of RHC pain a/w
fever and vomiting. O/E, she appears flushed with RHC tenderness and Murphys
+ve

This is consistent with the diagnosis of Acute Cholecytitis

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Surgical History Presentation
My differentials are: (consistent with earlier history)
1.Hepatic abscess
2.Diverticulitis AND
3.Right lower zone pneumonia

My investigations include LAB TESTS AND IMAGING STUDIES

For blood tests, I would like to order:

1.FBC for leucocytosis
2.RP as a BASELINE TEST
3.LFT to look for obstructive jaundice
4.Blood culture to identify infective organisms
5.CXR to look for pneumonia
6.ECG as BASELINE TEST
7.US HBS to look for dilated ducts or liver abscess
8.KIV a CT abdo/pelvis if diagnosis not clear on US HBS

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Surgical History Presentation
My management can be surgical or conservative treatment: (classify)

I would resuscitate the patient with fluids and Abx before offering
Laparoscopic KIV open cholecystectomy to the patient if there is acute
cholecystitis in the absence of common bile duct stones.

I would reserve conservative treatment using Abx and analgesia only if

the patient is unfit for surgery during the hospital admission and
consider interval cholecystectomy.

What if the patient has obstructive jaundice

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The Ideal Medical Student

Turns up
Curious
Knows about his/her patients
Knows his/her stuff
Good at presenting
Sociable, courteous

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The Goal of Medical Education?
University Education get a degree
Safe doctor
Academic
Researcher
Educator
Administrator
Salesperson
Good clinician
Or.

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M5 - How to Pass the MBBS!
Akan Datang in M5

How to prepare for the exams

Physical preparation
Psychological preparation

Expect the unexpected - How to get through the

exams

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TIME FOR A CHANGE !

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Questions?

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