I had the final exam in surgery-traumatology on the 28th of October (13:00). Me and another student waited outside the room which was written on Neptun (5th floor of 400 bed, to the right when you exit the elevator. Eventually the examiner fetches us into the seminar room (the same where trauma/surgery seminars took place). We draw topics, one from each of three envelopes, and are given time to prepare if we wanted.
There are separate examiners for the surgery part and the traumatology part. There’s no patient examination. While I had my surgery topics, the other student had her traumatology topics. The surgery examiner was Dr. András Papp. I did not catch the name of the trauma examiner.
After a few minutes of preparing, the examiner asked me whether I would like to start without preparation time to get over with it, and I was like “why not”. I believe I remember most of their questions, so here they are.
A12: Abdominal ischemia
Me: We can distinguish ischaemia of the large bowels and the small bowels
Examiner: What is the blood supply of the small bowels?
M: The coeliac trunk, SMA, and IMA?
E: And the large bowel?
M: The IMA, and the superior rectal?
E: Nononono, the SMA and the IMA. What is the border between the two systems?
M: The ligament of Treitz?
E: Yeah. The median colic artery comes from the SMA but the left sided colic arteries come from the IMA. What are the symptoms if the patient has abdominal ischaemia?
M: Severe abdominal pain, which ..
E: At all time?
M: Not always, but if it’s acute, then ..
E: It’s always acute. Can you tell me the symptoms when it starts and as it’s going on, what starts to happen?
[I had no idea what he’s going for here]
M: It kind of depends on the etiology, if there is an embolism there’s a sudden, out-of-nowhere severe abdominal pain, which they say is “out of proportion to the physical findings”.
E: Okay. And?
M: They can also have haematochezia
E: They can, yes. Is the pain constant?
M: It gets more and more severe
E: And then?
E: And then there’s no pain. After a while it starts again, and keeps going until death.
M: Okay, I didn’t know that
E: It’s really characteristic. The pain at first is really high, and then it gets better for a few hours, and when it becomes necrotic and reaches the point of no return the pain progresses again. What can you do when there is abdominal ischaemia of the small bowel but it’s only a few cm of the jejunum involved?
M: You can surgically remove the necrotic part?
E: Yeah. And then? What is very important in this operation? Can we do the resection and the anastomosis and the patient can go home?
M: We should also look for the cause of the ischaemia. We can do some interventional radiological methods like thrombolysis or thrombectomy to remove it.
E: Thrombectomy is not radiological, it’s surgical. Yeah, we can do that also. We can also do a resection. But what I wanted was that the patient often needs a so-called “second look” operation, where we check again whether there is other necrotic parts.
That was the end of this topic. I got a 4 on it.
B34: Perianal abscesses and fistulae. Surgical management of hemorrhoids.
M: Okay so perianal abscess is often primary, so there’s some clogging of the perianal glands which causes a subdermic [yes I said subdermic] abscess that’s visible as a bulging out of the skin which is red and very painful, especially during defecation.
E: And what is the temperature of the patient?
M: The patient has fever as well.
M: And there may be an internal fistula as well, from the anal canal to the abscess
E: Yeah they almost always go together. We can say that an abscess is an incomplete fistula. In what kind of disease can we frequently find fistulas?
M: Crohn’s disease
E: Yes. What is Crohn’s disease?
[this question is made for me]
M: It’s one of the two inflammatory bowel diseases where we can have inflammation of the whole GI tract, most commonly the terminal ileum.
E: Yes. What are the surgical treatments of Crohn’s disease?
M: It’s mostly used for adhesions and in severe cases you might have to remove bowel which is inflamed and doesn’t respond to medical therapy.
E: Yes. What is the big difference between the surgical treatment of Crohn’s and ulcerative colitis?
M: For ulcerative colitis total colectomy is curative, but there’s no curative surgery for Crohn’s. Treatment for Crohn’s is mostly non-surgical.
E: Yes, and if we need it we resect only the part which is inflamed.
E: Okay. Surgical treatment of haemorrhoids
M: So we classify internal haemorrhoids as 1, 2, 3, or 4, which …
E: What does the grade 4 mean?
M: It means that it’s not possible to retract it.
E: Yes, so it’s an absolute indication for surgery
M: Yes. So surgery is indicated for grade 4 and I think grade 3 as well
M: The others are treated mostly conservatively. There are many options for surgical treatment, like sclerotherapy, banding, haemorrhoidectomy …
E: What is actually a haemorrhoid?
M: Haemorrhoids are pouches or pillows of dilated veins
E: Yes, so it’s actually normal, but if they cause symptoms then it’s a problem. Okay, one more question for the 5. What is the Dixon operation?
M: [after thinking] I don’t remember
E: Okay, it’s an anterior resection of the rectum with a primary anastomosis.
This was also a 4.
B7: Foot fractures and dislocations. Achilles-tendon injuries.
I was given some extra time to prepare for the trauma topic. After a few minutes the trauma examiner asks me if I’m ready
M: I think I’m okay with achilles tendon injuries, but I find foot fractures and dislocations a bit difficult, but we can start.
E: Actually I think the achilles tendon injuries are the most important anyway. So you can start with this
M: Okay. So the achilles tendon is the largest tendon and injury of it is common in sports
E: Which types of sport?
M: For example sports where you have rapid turning and acceleration, like basketball, football, sprinting, volleyball, etc.
M: The patient often feels like someone “kicks” them at the tendon when it snaps. And they lose the plantarflexion, which we can examine with the Thompson test.
E: What is the Thompson test?
M: It’s when you have the patient prone, you compress the calf, and you see whether the foot is plantarflexing or not. If it doesn’t, it indicates achilles tendon injury.
M: So it’s controversial whether it should be treated surgically or conservatively …
E: Actually let’s talk about diagnosis. Which modality is good?
M: Ultrasound, or MRI.
E: Yes. Usually the ultrasound is enough.
M: You can also palpate a gap in the tendon itself
E: Yes. So treatment?
M: So like I said, it’s kind of controversial whether surgical or conservative is the best.
E: What do you think, which is better?
[he’s a surgeon so the answer is obvious]
M: I think surgery
M: Yes, probably because the recovery is quicker. It involves repairing the tendon, sometimes you might need a graft.
E: If the injury is fresh then you can just suture it. What can we do after the surgery?
M: Proper rehabilitation is important
E: Yes, very important. In which position is the rehabilitation?
M: What do you mean by which position?
E: Like, which leg position.
M: In plantarflexion
E: Yes, usually in the first 3 weeks. And after that?
M: Probably mobilisation and physiotherapy?
E: Yes, but in which position?
[guessing time 2]
E: Yes. And after 6 weeks?
[I’d run out of ankle positions so idk]
M: I’m not sure
E: After 6 weeks the patient can take off the brace and start to walk. Okay, please give me some words from the foot fractures.
M: Okay, so the most common is the talus and calcaneus fracture.
E: Okay, yeah [hesitating a bit]
[instant anxiety due to the examiner’s hesitation]
M: They can be due to high energy trauma like car accident, or falling from a height. So they can sometimes be bilateral. There is local pain, and there can be plantar ecchymosis.
E: What can you see if somebody has foot fractures?
M: You could see a deformity of the foot, and the patient cannot walk on it.
E: Perhaps a haematoma?
M: Yes, and swelling.
E: Okay. Diagnosis?
M: X-ray, maybe sometimes CT as well.
E: Okay. Could you tell me something about the toe fracture? I think those are more frequent fractures.
M: There are some named fractures, I’m trying to remember. Is Jones fracture on of them?
E: No, Jones is a 5th metatarsal fracture. Tell me about the toe fractures.
[I’d thought that toe fractures include metatarsal fractures but apparently not]
M: So they can be due to direct trauma. The patient will experience pain, difficulty walking …
E: And the treatment?
M: I would say it probably depends on if there’s dislocation or not and how severe the fracture is. If not dislocated and not severe then we can do conservative, if not then maybe we need surgery.
E: Actually only when the 1st toe is dislocated is when we use the surgery. In other cases it’s conservative, no matter the dislocation.
And that was it. 4 here as well.
So that was it, a 4 in total. It took probably 10 – 15 minutes excluding prep time. They both had calm, non-confrontational voices, and at no point did I feel like I was close to failing, which was nice.
I’m still annoyed, though. Most questions were simple and straightforward, but some were explained as a single sentence in a single presentation in one of the three surgery subjects we’ve had (second-look operation), hidden among a wall of text on lecture (characteristic pattern of mesenteric ischaemia), or never written in lectures at all (the position and timing of casting after achilles tendon rupture, fractures of the toes). I’m annoyed because I put so much time and effort and went through so much stress to prepare for this and write notes, only to have an exam which was relatively non-difficult but still being asked questions I could probably never be prepared for. But that’s not new here, unfortunately.
The password module is acting up, causing some problems, in some cases giving an “incorrect password” error message even though the password is correct. To work around this, try to access another password-protected page and enter the password there. It should work, and from then on the password-protected pages should remain unlocked for 30 days.
Here is the previous post. Unfortunately, I have bad news regarding the biyearly statistics. Sometime in March this year, the website started getting spammed, and it still is, every day. I don’t know why or how, but it happened. This luckily doesn’t cause any problems for the website, but it does skew the statistics because these spam visits are indistinguishable from visits from actual people. I’ve tried to implement measures to decrease spam visits, but they haven’t helped.
Because of these spamming bots, the visit count has increased drastically this semester, with the majority of visits now being from bots rather than actual humans. This makes it impossible to compare to previous semesters and to know the actual interest in the website. I’ll show you.
As usual, a page “visit” refers to opening a single page on greek.doctor. A “visitor” is a unique person within that day. This graph includes the page visits from the week before the beginning of the semester until the last day of the exam period.
I’d say the numbers are valid and realistic up until the middle of March. Before the semester began there were approximately 400 daily visitors and 1300 visits. In the beginning of March, the number was approximately 500 and 1600, respectively. However, after the beginning of the spamming there are approximately 700 visitors and 16 000 visits every day. Note also the spam peak on March 9th, with 43 900 visits.
Search engine referrals are probably unaffected by the spamming. The numbers are pretty similar to last year.
These are the last 20 search words people used before ending up at greek.doctor.
This statistic is one of the stronger proofs that the website is being spammed. It is the top 10 visitors of the website today. Compare it to the top 10 visitors from before the spam.
The top 10 visitors used to mostly be from Hungary, use modern browsers, and have sensible visits (hits) per visitor.
Time for a few fun comments!
I plan to write notes for some of the subjects in 6th year. I’ll write a new post soon with which subjects I’m going to write for and when.
Until then, enjoy your summer!
In Norway, 6th year medical students can be hired to do doctor work, mostly in wards. There are very few positions available, much fewer than the number of students who are interested, so getting hired for a position is more of an exception rather than a rule.
I was extremely lucky this year and actually got a position! My position is at one of the bigger hospitals in Norway, Akershus University Hospital, which you might recognise from a certain tiktok. I’m going to be working 7 weeks in the cardiology ward, doing rounds on patients, discharging patients, doing paperwork, etc. I had my first day yesterday, but today was the first day where I was responsible for my own patients. I’ve gotten this period accepted as my 6th year internal med practice.
On this day I:
Wrote my first ever prescription
Did my first ever rounds
Wrote my first ever application to the state for sick leave for a patient (who had an AMI)
However, I also managed to:
Introduce myself as “Nikko” to one of the chief doctors
Say “sorry for crushing your dreams” to a nurse who asked me if she could measure NEWS less frequently, making my collegues laugh at my choice of phrasing
Misunderstand the computer system, making me think that blood culture on a septic patients had not taken for no good reason (while in reality they were taken)
Need to work 1 hour overtime to get done with all my tasks
… but it’s all good, because a nurse told me that she thinks I’m doing a good job.
So I had my gyn 2 exam on Thursday. It began at 8:00, before which we’d been waiting outside the building where ENT lectures and ob/gyn seminars took place. At 8, a woman comes and tells us to follow her to one of the seminar rooms. We were only 5 students who took the exam that day and so we were all allowed to prepare simultaneously, inside the room. Each of us drew two topics randomly, one from each pile. I drew A9: Cervical cancer, symptoms and diagnosis and B7: The most common childhood gynaecological disorders, the first of which was very good and the second which was meh. I was the fourth person to have the exam, and all exams took place in the room where we were preparing. The examiner was dr. Bálint Farkas.
A9: Cervical cancer, symptoms and diagnosis
I began with this topic as it was by far my strongest one. Dr. Farkas had the lecture on this and I’d watched that lecture, so I felt that I knew exactly what he wanted to hear. I began with an introduction of cervical cancer, with special emphasis on it being a “controllable” cancer as he’d put it himself in the lecture. I continue with the risk factors and symptoms, as I’d written it down.
I then talk about the pap smear, emphasising how it’s a cytological classification, and basically saying what I’d written down. Before I get the chance to talk about CIN, he asks me what CIN is, so I continue with that. Basically continuing with what I’d written down.
He asks me “what could be the treatment of a stage Ia1 cervical cancer?”, to which I answer “conisation”. He then says “yes, and what if the patient does not desire pregnancy?”. I answer “then we can do total hysterectomy with bilateral salpingo-oophorectomy”, to which he agreed. He had no other questions to this topic, and we continued to the next.
B7: The most common childhood gynaecological disorders
(You can tell that I didn’t really know what to talk about here. Also, I wrote the stuff about dysmenorrhoea in the middle of the paper after my exam, to remember what he told me.)
This was a much less confident topic of mine, as I don’t really know what to talk about here (which is why I’d written down so much random stuff during prep time). I began with vulvovaginitis, basically saying what I’d written down about it and nothing else. I pause for a bit as I’m pondering what to talk about next, until he interrupts my thinking with the question “what is dysmenorrhoea?”. I reply that it’s painful menstruation. He then asks what primary and secondary dysmenorrhoea is. I’d never read anything about primary and secondary types, so I didn’t really know. I guessed that endometriosis was a primary type, to which he said that that’s rather a secondary type. At that point I understood that primary probably meant idiopathic, so I said just that, which he agreed with. He starts explaining how primary dysmenorrhoea may be related to learned behaviour from family somehow. He then asks for causes of secondary dysmenorrhoea. I repeat endometriosis, and after thinking for a bit I say fibroids, to which he agrees. He then asks, “what’s it called when endometriosis invades the uterine wall?”, to which I respond “adenomyosis”, which he says is another cause.
He then says “there are two other causes as well, but you’re probably not going to guess those. They are cervical stenosis and intraabdominal adhesions”. He was right about me never going to guess those.
At this point my exam is already over. He says that this was excellent, and the co-examiner shoots with a “this should be a 5+”. Dr. Farkas tells me to “keep up the good work”, which was a nice ending to the exam period.
I was super lucky with my A topic. I think I got off the hook easily on my B topic because I did so well on my A. In either case, he was quite nice and understanding. To be honest, when he entered the room he seemed to be in a bit of a bad mood, but it turned out that he wasn’t at all. Everyone who had the exam that day got good grades, even though all of us said some really wrong stuff (something about micropenis in Turner syndrome) and sometimes needed a lot of help to getting to the right answer.
That marks the end of my 5th year, and the end to my last ever “conventional” exam period, which I am eternally grateful to be done with.
I had my neuro 2 exam today. The exam would start at 9 according to neptun, but the day before we got an e-mail that it would start at 8 instead. The exam was at the rehabilitation clinic next to the neurology department. The examiner was my teacher in Neurology 2, the course director of the subject, prof. Endre Pál.
I was one of the last persons to go in. I draw topic 28, with obstructive sleep apnoea syndrome and Huntington disease. We got a few minutes preparation time if we wanted, during which I made this:
28A. Obstructive sleep apnoea syndrome
I mentioned what I’d written down about OSAS. He asks about two indexes which are measured during polysomnography. I guessed one of them, the apnoea index. He told me that the other one is the oxygen saturation index. I don’t think I had any other questions on this topic.
28B. Chorea, Huntington disease
I begin by defining chorea, and mentioning the most common causes. He asks me what a stroke-induced chorea looks like, and I said hemichorea, which was correct.
I then talk about Huntington, just basically what I’d written down. He asked me which diseases it’s important to rule out in case of Huntington, and he remembered he’d mentioned in the seminar that it’s important to rule out Wilson and Parkinson. He asked how we could do that, and I answered serum/urine copper and ceruloplasmin for Wilson. For Parkinson I said SPECT or PET, which he said was a possibility. He asked me what Parkinson disease patients respond to, and I answered levodopa, which was correct. He said that in ambigous cases we could give levodopa to the patient. If the symptoms improve, it’s PD, if they worsen, it’s HD.
He asked me what anticipation was, which was funnily enough something I learned in genetics two weeks ago. I explained that it means that the disease becomes worse and worse with each generation, to which he agreed. He asked me a couple of other questions as well, but I don’t remember what. In the end he gave me a 5.
Prof. Pál is a very kind person, a good teacher, and an excellent examiner. The atmosphere of the exam was calm, he was not strict, and I’m pretty sure he passed everyone that day.
So I had my A&IC exam today. It was a bit of an experience, especially an unexpected one. I’d heard that the exam is with no prep time and just 5 minutes, but the exams today were with preparation time and they took much longer than 5 minutes.
I’m not sure who the examiner was, but after looking at the department site I think it was Dr. Tamás Kiss. I don’t know who the co-examiner was.
Me and two Hungarian students enter the K001 seminar room at 400 bed clinic at 9:00, and we’re told to sit down with some distance. They ask who wants to start, and we agree amongst ourselves that I should start. I draw two topics from separate envelopes. I get:
14. Mental disorders, drug overdosed patients (the unconscious patient and toxins)
4. Pharmacology of inhalational anaesthetics
I expected to start the exam right away, but instead they gave me the paper to start preparing, which was a surprise. I hadn’t even brought a pen because I thought there wouldn’t be prep time. Anyway, I start preparing.
Even though I started preparing first, one of the other student finished before me, and so started the exam first. Their exam was in Hungarian, so I couldn’t understand much of what they were saying. From what I gathered, he was talking about monitoring during anaesthesia, and there were some things he’d forgotten to mention and the examiner spent A LOT of time helping him remember them. I think his exam lasted around 40 minutes. During this time I was thinking of how different this exam is going to be from my expectations.
After a while it’s my turn. I begin with my first topic.
14. Mental disorders, drug overdosed patients (the unconscious patient and toxins)
I began by saying that I can talk about the disorders of consciousness, to which he agreed. I mention the three types. Then I talk about the I WATCH DEATH mnemonic, which I’m not sure I remembered correctly but I didn’t make any comments about it. I also talked about the GCS. He then asked me about a simpler way to scale the patient’s consciousness. I barely remembered (after some help) about AVPU, and he asked me what it stands for. I barely remembered that as well.
I say that I can talk a bit about delirium here as well, which he agrees to. He mention what I’d written down. He asks me about what can cause delirium in the ICU specifically, as opposed to other hospital wards. I guess lots of things, like infection, sepsis, shock, postop, etc., but he says he’s after “something much simpler”. “Think about the typical patient. Who are they?” I say “elderly”, and he’s like “yes! exactly, simply old age and dementia can cause it”. Then he’s after another thing as well. Eventually he tells me “What’s different in the ICU compared to other wards? What happens at 2 in the night in the ICU?”, at which point I understand that he was talking about sleep deprivation, which was correct. He says to move on to the next part, the drugs.
I begin with the sympathomimetics, and before I can mention the symptoms he asks me what the symptoms are. He then tells me to talk about opioids, and I mention what I’d written. He asks me about the respiratory pattern in opioid intoxication. I mention that it is very slow and shallow, which he degrees with. He says that it’s deep rather than shallow.
At this point he says he’s happy and that we should move on to the next topic. I never covered the other drugs.
Pharmacology of inhalational anaesthetics
I begin by mentioning that inhaled anaesthetics are lipophilic drugs, and the more lipophilic, the more potent, the slower the onset, and the slower the recovery. I tell him the definition of MAC, after which he stops me and tells me that MAC isn’t really a measure of potency, for some reason he explains to me which I don’t really understand. He then asks which alveolar concentration of anaesthetic we use in general anaesthesia, to which I reply “1,3 x MAC”. He say’s “1,2 – 1,3, correct”.
I then mention point 3, before I talk about halothane. I mention what I’d written, and I continue to the halogenated ethers. I didn’t remember any of the specific effects of them during prep, so I hadn’t written any down as you can see. I continue to nitrous oxide, and mention what I’d written. He asks me about which other effect N2O has, aside from the anaesthesia itself. I guess “analgesia”, which was apparently correct.
He asks about situations where we could use it in alone. I mention procedures like dental procedures or colonoscopies, but they weren’t really what he was after. He says “in which situation do you think it’s an advantage that the patient does not completely lose consciousness, but is pain relieved? Think of younger women”, at which point I guess “during labour”, which was correct.
He then circles back to halogenated esters, probably because they’re the most widely used but I didn’t mention a lot about them. He says that there are three effects of them on the body, and he wants me to mention them. I remember that they increase ICP, which was correct. He asks me how they do that, and I guess that they vasodilate cerebral arteries, which was correct.
He then says “if they vasodilate the cerebral arteries, what do you think happens with the other arteries in the body?” I guess that they vasodilate as well, potentially causing hypotension, to which he agrees. I say that they have a depressant effect on the heart, to which he agrees and then asks which of them have the least cardiodepressive effect. I had noe idea, so I guess one of them (don’t remember which one), but it was the wrong one. I don’t remember which is the right one.
He asks about the last effect. I don’t know, but he tries to help me by saying that it affects the respiratory system. I remember that some of them cause airway irritation, so that they can’t be used for induction of anaesthesia. He agrees, but that wasn’t what he was looking for. He asks me which of them that can be used for induction. I guess one of them, but it was wrong again. Don’t remember what I guessed or what was correct.
He’s still waiting for the third effect of these drugs. He tries to help me by saying that it’s a very useful effect in the ICU. I had a small hunch that it was bronchodilation, so I guessed it, and it was correct.
He asks me about which patients it’s preferred to use inhalational anaesthetics for induction rather than IV. I remember from the paediatric anaesthesia topic that it’s better for young children, which is what I tell him and he’s very happy. That was the end, and was very satisfied and gave me a nice 5.
It was a very different experience from what I expected. I expected a short exam with no prep, not this. But he was very enthusiastic when I gave right answers, and he didn’t seem to mind wrong answers too much. He gave helpful hints and was patient, but perhaps a bit intense. I was kinda lucky because 1,5 of my topics was mostly pharma and the other half was mostly psych.