Internal medicine final exam experience

So I had my internal medicine final at 1st department on the 21st. A notice on Neptun told us to meet at the “Clinical and Educational office” in the B wing of the 2nd floor (room B227) at 8:00, and to bring our 8 case reports and certificate of finishing the practice. When we arrived, they took photocopies of the case reports and certificate, and gave us a paper which we were to bring to the practical part of the exam. We were told to wait outside, and eventually prof. Gabriella Pár comes and gets us and gives a patient each. We were two students per room, each with their separate patient. She tells us that she’ll be back to ask what we’d found in 30 minutes.

Practical part

I introduce myself to the patient and begin taking the anamnesis and performing the physical examination. After me and the other student finish with each of our patients, we leave the room and wait for the professor in the hallway while we collect our thoughts on the patient. While waiting, my patient comes out of the room and offers both of us some tea ❤️.

Eventually, after maybe an hour, the professor arrives. She asks me what I’d found, and I begin presenting my findings. My patient had arrived to the hospital due to abdominal pain which occured after eating. She stops me and begins asking questions.

• Examiner: What can cause abdominal pain after eating?
• Me: For example gallstones and gastric ulcer.
• E: Yes. In case of duodenal ulcer, when does the patient have pain?
• M: At night
• E: Yes, and two-three hours after eating. What else can cause abdominal pain after eating?
• M: Acute pancreatitis.
• E: Yes. In case of gallstones, where does the pain radiate?
• M: To the shoulder (thanks to my fellow student who just told me this before my exam, otherwise I might’ve not remembered)
• E: Which shoulder?
• M: The right shoulder (I had to think for an embarrassingly long time to recall which side the gallbladder is on)
• E: And in case of acute pancreatitis?
• M: It radiates to the back.
• E: Why does the pain in acute pancreatitis radiate to the back?
• M: Because they share the same nerve supply? (I don’t remember what I said but it was something vague like this)
• E: Something like that. What are the risk factors for gallstone?
• M: It’s the six F’s: female, forty, fat, fair-skinned, fertile, …, and I can’t recall the last one
• E: Does your patient have any risk factors for gallstones?
• M: He’s fair-skinned and overweight.
• E: Anything else?
• M: (thinking but can’t recall anything)
• E: What are the types of gallstone?
• M: Cholesterol and pigment stone… oh, so dyslipidaemia is a risk factor.
• E: Yes. How can you tell that your patient has dyslipidaemia?
• M: (I couldn’t see any xanthomas or xantholasmas, so I don’t know)
• E: It’s a question you asked your patient.
• M: (What question could I possibly have asked to determine that)
• She looks at the paper in which I’ve noted my patient findings and points at the medicine list.
• M: I could ask if my patient takes statins?
• E: Yes, exactly. Does your patient take statins?
• M: I’m not sure. He told me that he takes heart medicine but I didn’t ask more specifically. He wanted to show me the list of medications but he couldn’t find it.
• E: It’s okay. What other question you asked could show that he has dyslipidaemia?
• I look back down at the paper
• M: He had a myocardial infarction in the past
• E: Yes, exactly. What side effects can statins have?
• M: It can cause myopathy or liver failure, for example.
• E: What is myopathy?
• M: Inflammation of the muscle which can cause muscle weakness and pain.
• E: And what abnormality can you see on the labs?
• M: Elevation of creatinine kinase.
• E: Yes. What can be a complication of rhabdomyolysis?
• M: It can cause kidney failure.
• E: Good. How much alcohol does your patient drink?
• M: He said he drinks only a little, but I don’t know how to ask more specifically.
• E: Okay. What’s the daily limit of alcohol intake?

This is something I wouldn’t have learned unless a friend of mine had gotten the same question and warned me about it, so I looked it up in the lecture.

• M: It’s 20 – 30 g for men and 10 – 20 g for women.
• E: Yes. How much alcohol is there in one beer?

I’ve always thought that one beer was one unit, and I’m pretty sure it said on the lecture that one unit is 10 g.

• M: It’s 10 g.
• E: No, that’s not correct.
• M: But it depends on the strength and size of the beer, right?
• E: Okay, how much alcohol is there in 1 dl of regular beer?
• M: 3g? (pure guess)
• E: No, it’s 4 – 5g. So how much in halv a litre?
• M: 20 – 25g.
• E: Yes, so one beer is already above the limit for women and above the limit for men. Please show me examination of the liver.

I percuss the border of the liver.

• M: His liver is 1 finger below the costal arch.
• E: Okay. What can cause the dull sound over the liver to disappear?

That’s a problem I’d never considered or heard of before, but I figured that the only way it can disappear is if air gets between the abdominal wall and the liver.

• M: If there is air in the abdomen?
• E: Yes. How can you diagnose air in the abdomen?
• M: You could use x-ray or CT.
• E: How would you see abdominal air on x-ray?
• M: There would be air under the diaphragm.
• E: When the patient is in which position?
• M: When they are standing.
• E: And if they are lying down?
• M: Then it would be beneath the abdominal wall?
• E: Yes. What can cause abdominal air?
• M: A perforation
• E: Perforation of what?
• M: The gastrointestinal tract.
• E: Yes. What is the treatment for GI perforation?

I was kind of confused, because I know of no internal medicine-related treatment of GI perforation. Could there be an endoscopic procedure? No, there can’t be. It has to be…

• M: Surgery?
• E: Yes. So it’s a surgical problem and not an internal medicine problem.

And that was the last of the question on the practical part. She writes a 5 on the paper from earlier, and signs and stamps it (of course). She tells me that my examiner will be prof. Alizadeh and that the theoretical part will take part in the science building in room B001, and that he’s impatient and that I have to hurry there, so I thank my patient and rush over there.

Theoretical part

After rushing over there, I found like 10 students waiting outside the room. They’d also been told to hurry, just to have to wait when they got there. One person already finished their theoretical exam but didn’t get their grade because the examiners had told them that no one will get their grades until all 11 students have finished their theoretical examination. So I sit down to wait. After the 9 students before me have finished, it’s my turn. I go into the room, sit down in front of prof. Alizadeh of haematology and (I think) prof. Tótsimon of cardiology. In my fluster I tell them “good afternoon” even though it was like 10:30. As I sit down, Alizadeh leaves the room, presumably to go to the toilet. Prof. Tótsimon begins the questioning in his absence.

• Examiner: Tell me about anticoagulants. Which types do you know?
• M: You have the vitamin K antagonists like warfarin or dicoumarol, the DOACs like dabigatran and apixaban, and the heparins, both unfractionated and LMWH.
• E: Good. In which cases do we use anticoagulants?
• M: Anticoagulants are used in case of atrial fibrillation to prevent stroke, in DVT/PE, and in acute myocardial infarction.
• E: Good. There’s one more.

I try to think but I can’t recall it.

• E: It’s also used in nephrotic syndrome, but it’s okay if you don’t know. (I actually did know but I’d never thought of that in a million years)
• E: When do we use vitamin K antagonists and when do we use DOACs?
• M: Generally, VKAs are only indicated in case of prosthetic heart valves or in case of moderate or severe mitral stenosis.
• E: Good. In which case of atrial fibrillation do we use anticoagulation?
• M: If the CHA2DS2-VASc score is 1 in men or 2 in women.
• E: Actually in case of 1 for men or 2 for women, anticoagulation can be considered, but if it’s 2 in men or 3 in women, then it’s recommended. But it’s good, your answer is good. Do you remember the parameters of the CHA2DS2-VASc score?

This is something I imagined could be a question, so I’d prepared for it. I close my eyes and try to visualise the mnemonic. To my own surprise, I recite it correctly.

At this point prof. Alizadeh returns to the room. Prof Tótsimon quickly explains him in Hungarian what we’ve talked about so far. Prof. Alizadeh continues:

• E: So my colleague tells me that you’ve talked about anticoagulants and that you’ve answered excellently so far. Now, please tell me. What are the antidotes for DOACs?

I was not prepared for such a pharma question. I remember studying it in pharma but I hadn’t looked at it since. We spend some time in silence as I try to dig deep into my memory for the information, but I can’t recall it.

• E: Okay then please tell me, what are different types of DOACs?
• M: You have dabigatran, which inhibits factor II and X, and the others like apixaban and rivaroxaban, which inhibit only factor X.
• E: Dabigatran inhibits only factor II, but yes. Now, each of these groups have different antidotes. Please tell me what they are. The antidote for dabigatran begins with an “I”.

The hint made some gears turn in my head.

• M: Is it something like idarocumab? (I don’t recall exactly what I said, but it was something like this, which was not very close to the correct name)
• E: Yes, it’s idarucizumab. The antidote for the others are andexanet alpha and ciraparantag. Now, for a better grade, please tell me the newest drug for atherosclerotic ischaemic heart disease.

At first, I’m like, what. I’m pretty up to date on cardiology, but I can’t recall any new drugs for that indication. I know that SGLT2 inhibitors were recently indicated for heart failure as well. Could that be what he meant? But that’s not related to atherosclerosis.

• E: It’s four letters and a number. It’s an injectable drug.

Okay, but then it has to be them, right?

• M: SGLT2 inhibitors?
• E: No, that’s for heart failure.

I knew it.

For the next part, I believe they gave me a hint which put me on the right track to the answer, but I can’t recall what the hint was. It might’ve been the first letter, “P”.

• M: It’s PGSL2 inhibitors, or something (I don’t recall exactly what I said, but it was nowhere close to the correct answer lol)
• E: Yes, it’s PCSK9 inhibitors. It’s okay, please go out and wait for your grade.

Epilogue

After waiting for the 11th student to finish their exam, everyone went back into the room one at a time to get their grades. As I enter when it’s my turn, the examiners are already on their way out, so I think they kind of forget about me. As they walk past me, they tell me that I got “excellent” and congratulated me.

And that was it! That was my last ever exam at POTE. Now only state exams remain. I was surprised to be asked such an amount of pharma questions, but anyway.