FOURTH YEAR

*The modules are consistent with MB21 year 4 but some details may be out of date*

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INTRODUCTION

This is the year things start to get serious and you’ll feel the weeks getting longer and the exams harder. But with that will come more confidence on the wards and closer to being a doctor. You will continue to learn about other specialties such as Pathology, Obstetrics and Gynaecology, GP and care of the elderly. Much like year 3 you will spend half of your year “on placement” outside Bristol.

Fourth year is a really enjoyable year. But is it long and generally considered to be the hardest year there is. Nevertheless, you do get involved more clinically and there are more opportunities available.

Below are just some aspects which will hopefully make made fourth year a bit easier.

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Community Orientated Medical Practice 1 (COMP1):

Paediatrics and Epidemiology

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Epidemiology

3 weeks of lectures taught at Canyge Hall. Good to be in Bristol for 3 weeks.

The problem is the SSC. Ruins the experience of Paediatrics where you would much rather be doing clinical activities! But my advice would be just do it asap and get it out of the way. Also choose a question which compares two treatments as then you are more likely to be able to find RCTs and papers which are easier to analyse.

There are really good examples of essays so look at them. Just follow the mark scheme, keep it logical and you will definitely pass.

With respect to revision: learn the DEFINITIONS!!! And public health (Including Millenium Development Goals). Do all the practice questions which are online and that you are given. Also, go through the booklet and go over the examples again to ensure that you understand how it is done. Exam was fair.

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Paediatrics

Enjoyable unit. Very different as to whether you do it at the Children’s Hospital or in the Academies outside of Bristol. In BCH you actually don’t see many children. You see awesome and exciting patients but when it comes down to it there are too many distractions in Bristol and people don’t generally go onto the wards.

Textbook which will make you pass: Lissauer and Claydon. Really easy to read and has everything you need to know. Also if you buy it there is a code at the front of the book to log on to Student Consult and the online resources are really good. It contains MCQs and good revision summaries. I would really recommend it, especially when you are struggling with revision!

Exam: Written – the exam I sat was really fair. Learn Lissauer and you won’t have any problems. Liver syndromes eg Crigler-Naigler, Dubin-Johnson have come up in the last two lot of exams. So has Potters Syndrome. Also know about Downs Syndrome.

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OSCE:

2x examination
2x communication
2x interpretation
2x video

After all the examinations remember to say that “To complete my examination I would… eg obs, sats, temp, peak flow etc depending on the examination.

And PRACTICE presenting. This really shows who the top students are. If you can look confident whilst presenting it really helps.

Tips for examining children:

• Have some banter with them eg ask them about school, how old they are, did they get a day of school, are you a naughty boy etc?

• Talk to mum at the same time. The reassures both mum and child. When examining you can show on mummy eg just going to tap on mummy’s chest. See it won’t hurt. Also you can get them to listen to your chest etc if they are worried.

• If child clearly has ADHD don’t panic – just run with it and do opportunistic examination. Examiner will be understanding

• Specific bits of advice: when looking in eyes – get the child to pull eyes down “to make a funny face”, with JVP get them to look towards you when examining the neck. Always palpate liver. Tickle their tummy etc.

• Neuro – “I want you to show me how strong you are… I bet I’m stronger than you” Put your arms like a chicken.. like a boxer, or lower limb – try and kick me

• Resp: when listening to back of the chest try not to listen over the scapula and to listen more medially

• Cranial Nerves – you probably won’t get this and if you do it is likely to be in an older child. But is younger then be opportunistic and use toys as tools to do their eye movements etc.

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OSCE Stations 2007:

1) Communications station: scenario given to us a week beforehand.

• Febrile convulsion. (explain to anxious parent what a febrile convulsion is.)

• Intersucception.(anxious parent describes red jelly stole – diagnose.)

• Headache. (child missing school w/ headache. Check social hx. Child just moved to new school, faking headache, not many new friends, mother staying home to treat him.)

2) Upper or lower limb neuro ex.

• The child may have some other pathology eg renal bruit in arm

3) Respiratory ex.
4) CVS ex.

• Wash hands.

• The child is likely to have nothing wrong, so if you don’t hear anything, probably because there is nothing, so just say that.

5) Growth chart. (Plot figures + answer qu’s relating to it, remember to turn page over).
6) Drug dosage. (scenario, find drug using BNF, work out correct dosage, will be a antibiotic of some sort.)
7) Video – 1st video: describe 3 things the child can do
2nd video: describe what child can’t do, has cerebal palsy.

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OSCE Stations February 2009:

1. Resp exam – make sure say “kid small or some comment of that effect” Also palpate the liver and say you would like to do an ENT examination
2. Neuro exam – I had a kid with a pelvic abscess but it was meant to be a peripheral neuro exam… obv no neuro signs – just reduced power. He also was dyspraxic – so ask how walk normally (or talk etc… depending on the symptoms)
3. Video – had to say signs the kid had of developmental delay (motor signs) kid had cerebral palsy. But also know about equipment the kid used. I didn’t have a clue!
4. Growth chart – was CF, easy
5. Drug prescribing – remember kids can’t take tablets so you need syrup. Also time was quite tight on this station
6. History taking – just go through it logically, make sure you ask about social history and what mum is worried about. Also really important to make a plan. Say what you are going to do and reassure
7. Breaking bad news – errr.. this was pretty bad – so ask someone else! We had to say kid may have downs – once again make a plan and reassure (but I didn’t do very well/well at all on this station!)

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Knowledge:

• Dr Tulloh’s cardiology notes (really good) and also if you are in Bristol go to one of his clinics

• Development

• Know the core problems which present in early childhood and when and how they present eg intussuseption, pyloric stenosis, testicular torsion, celiac disease

• Asthma and know the stepwise treatment and the different characteristics of a severe and lifethreatening attack

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Community Orientated Medical Practice 2:

Care of the Elderly, General Practice and Dermatology

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Assessments

Written Paper: Care of the elderly, General Practice and Dermatology

This was quite tough. It focused on clinical cases and you had to say how you would diagnose/treat them.
Revision: read the booklets (even though that seems like a really way of revising, but it works and that is all you need to know)

Useful resources:

• Gawkrodger Dermatology (lots of detail)

• Oxford Handbooks on General Practice and Geriatrics (Really really good and in exactly the right style/content which we need to know just in a more accessible format than the booklets)

• www.dermnetnz.org (brilliant website)

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OSCE: *The majority of the marks*

This is a really fair exam. They test you on what is common presents commonly. All of the history taking stations will want to focus on the presenting complaint so PMH etc will all be minimal.

Overall tips:

• Keep calm

• Pretend you are a doctor

• Start with 2-3 open questions

• Check allergies wherever possible

• Practice, practice, practice. One evening before the week of exams do some OSCE practice as I found that helped direct your revision slightly especially as the OSCE is such a large proportion of the marks. And the best revision for this is to with a friend reenact the consultations as there is nothing like actually saying it.

• Make sure you ask questions like what has the patient come in for, what are they expecting, come back in 1 week, give them leaflets and ensure they know they plan of what is going to happen. Ask family history and find out worries.

• Provide literature and safety net

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Stations Summer 2009

1. Dermatology Written
Task: 3 pictures and had to write

• Case scenario: Atopic Eczema (Quite straightforward about a boy who came out in a rash. Ensure you write ATOPIC eczema otherwise you don’t get the marks)

  • Also had to write 3 risk factors/things that had caused it

  • Treatment regiment including doseage and strength and guidance (ie quite detailed)

• Case scenario: Alopecia areata (Barn door obvious pictures showing someones scalp. diagnosis once again ensure you write alopecia AREATA)

2. Dermatology Viva

Tips: actually not that easy coming up with 3 treatments for psoriasis and accounting their advantages and disadvantages in detail. Need to know greater detail than for the written. But only on the core topics

• Picture 1: Psoriasis – had to describe the lesions then discuss three different treatments and their advantages and disadvantages.

• Picture 2: Palmoplantar psoriasis and then describe the treatment

• Picture 3: Scenario and picture

• Patient with a history of psoriasis. Flare up. Picture of psoriatic erythroderma.

3. Consultation: A & E: Fall
Scenario: Patient had come into A and E due to a fall. Ask standard fall questions. They want you to ask what happened:

• Before fall

• During fall

• After fall

Also ensure you ask: collateral history, colour of patient during fall, loss of consciousness. Management and plan: make sure you know which investigations you would do eg 24hour ECG was what they wanted

4. Consultation: GP Reflux and alcohol
Patient presented with barn door history of reflux.
Take the history and what I did was at the end of history of presenting complaint ask about the risk factors which could increase reflux. Alcohol came up. Ask how much drink (I didn’t know how many units in a pint… 3 apparently!) Look at the behaviour change guidance in the GP booklet and then talk about management under two broad headings of conservative and medical.

5. Consultation: GP Migraine Management
Patient with long standing history of migraine. Very stressed at the moment and migraines getting worse. She wanted treatment. Her friend had been prescribed a triptan with a weird name.
Know about side effects of triptans and when you are supposed to take them

6. Consultation: GP Depression in Carer
Patient came in due to advice from health visitor. Her father has got severe dementia and she is struggling. Explore current situation, what’s going on etc.

7. Consultation: GP Angina
Patient presented with chest pain when walking up Park Street. Barn door angina.

• Remember to explore differentials to rule out others just in case (quickly)

• I got good feedback for having some banter with the patient at people generally struggling to walk up Park Street.

• Management and plan: REFER!!!! Needs exercise ECG. I also said I would prescribe some GTN and see if that would relieve symptoms, and she could use it in advance. He said that was good in the feedback but I’m still not convinced that was the model answer!!

• Also gave brief lifestyle advice (and a leaflet!!!)

8. Written: Pseudodementia/Depression
Situation describing patient who was confused. Looked like dementia but on the Folstein the concentration was decreased so that indicated depression rather than dementia.
Had to write investigations, assessments, treatment.

9. Examination: Cranial Nerves 
Scenario: Lady came into A and E because earlier that day she had difficulty swallowing and talking. Now totally recovered. Do a cranial nerve exam (no need to do fundoscopy, gag and corneal reflex)
Straight forward CN exam. Keep calm and go slow.
Ensure you do rinne and webers
Also look in the throat and ask to say Ah to look for lifting of the palate and deviation of the uvula.

10. Disability: Peak Flow
Visually impaired lady in the corridor. You have to go and get her.
Make sure you ask:

• I understand you have problems with your eyesight. Would you like to be guided? How?

• Once she’s in the room; Is the light in here alright for you? There is myself here and I am sitting opposite you etc and there is also an examiner in the room too.

• What do you think you are here for today? Peak flow. Great that’s what I expected too.

• Have you ever done this before? Even if they said yes, I just described what I was doing ie just fitting the mouth piece on. Then if you make good seal with your lips, blow as hard as you can etc… I will look at the dial. Need to do it 3 times and we will take the highest value

 

Stations Easter 2009

• Drug history

• Deaf person with UTI

• GP lady with cough, had to refer for xray

• Upper limb neuro exam

• Blood pressure, calculation of CV risk

• Falls history

• GP morning after pill consultation

• Dermatology acne

• Dermatology written of skin cancers

• Care of elderly written Pressure sores

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Stations February 2008

• Man comes in with reflux. CAGE and depression score needed

• Dermatology: you are told a 19 yr old presents with acne

• 47yr old lady comes in for annual medication check up having been on ACE-I & statin for a year.

• Communicating with deaf person – lady had UTI

• Do a CVS exam and discuss an ECG

• Starting warfarin

• Lady with persistent cough

• Pressure sore/leg ulcer – know causes, treatments.

• Atopic eczema – know causes treatments

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Stations February 2007

• History Station. Lady with lung cancer,

• Women comes in for the morning after pill.

• Women in hospital, has broken wrist from a fall. We were told take some history of how it happened and assess her for discharge.

• Written Station – Dermatology Pictures and Questions section.
  a. Brief hx of someone with actopic eczema. Write causes and treatments
  b. Second question was a photo of pemphigus.

• Care of the Elderly written. This was a double-sided sheet of questions with a list of drugs (6-10) and questions like which drug might cause postural hypotension.

• Back pain.

• Dermatology Viva. All about skin cancer.

• Blind person. – Peak flow

• Man who lives with Dad who has Alzheimer’s.

• CVS Exam. Man has dizziness, ?postural hypotension. Do a lying and standing BP.

 

Knowledge

A couple of aspects which are really core knowledge a I would advise knowing about:

Care of the Elderly

• Causes and differentials of dementia and delirium

• How to do a fall history

• Different treatment options after a TIA/Stroke

General Practice

• Attendance and Disability allowance

• The pages full of text about how General Practice works at the front of the booklet

• RED FLAGS and when to refer

• Investigations to do after presentation of specific condition

• And when investigations would be done on referral

• Type 2 DM

Dermatology

• Skin cancers: BCC, SCC, MM

• Common dermatological conditions: psoriasis, eczema, acne and how to treat

• Venous/arterial ulcers

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Applied clinical sciences(ACS):

Pathology and Anaesthetics

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It is a widely held belief which is reinforced year on year that this unit is pretty tough!! But, it does make medicine make sense so that is really encouraging but your coffee intake increases dramatically and you help fund the WRVS.

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The unit begins with three weeks of lectures on level 9 of the BRI, so it is nice to be in Bristol. And is also composed of Pathology tutorials and 3 weeks of anaesthetics. The precise logistics do vary depending on which academy you are in.

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The SSC is a presentation and can be of either a pathology or anaesthetics topic. When doing presentations ensure you remember all the standard presentation tips:

• Overview slide

• Choice of topic

• Clear slights with as few words as possible per slide and lots of pictures

• Vertical themes (Ethics goes down well)

• References

• Make sure you stay within the time limit

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Case studies are also a good idea; you don’t have to do a topic which would involve using loads of papers and fine detail research which has taken you ages.

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There is a mock exam covering both Path and Anaesthetics. This is really useful, but much easier than the real thing so just bear that in mind!

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Pathology

The exam on the computer and was in two parts with an hour maximum on each. The majority of questions are EMQs, and I can’t remember exactly how many there were but it was split relatively evenly between the different topics eg haematology, biochemistry, histology and microbiology.

My biggest tip would be when revising think clinically. The exam is notoriously tough, and a word of warning that questions will have a detailed accounts of cases, which when you read you think confidently that you know what the diagnosis is, but then they tell you that and the options are often to do with treatments and investigations (especially with respect to Haematology). Revision is really good to do with others as well to discuss cases.

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Anaesthetics

A really enjoyable placement. Very practical. The anaesthetists are really friendly and try to sell anaesthetics to you. The only problem is the early mornings, but generally you are able to leave early afternoon. Get all cannulae and LMAs done by going to theatres and if you are having difficulties with them then ask and the doctors will be really keen to help.

With respect to the exam Tim Lovell does a really good revision day. For the exam know about shock, pain relief and the pain ladder, emergencies – but I can’t remember much else about it!

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Reproductive Health and Care of the Newborn (RHCN):

Obstetrics, Gynaecology, Care of the Newborn and Sexual health

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Author Comment: Despite knowing I have no desire to become an obstetrician or gynaecologist this has been my favourite unit this year by far! It is really well organized with excellent teaching.

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Portfolio

Infamous and rumoured to be a more than a mouthful. However, even though initially it seems very daunting, it is well structured and all the components are those which you would generally complete anyway (even though it does get a tad tedious REMEMBER to get everything signed off as you go along because you don’t want to be chasing consultants around wanting their autograph).

Semi-structured cases…

• Do take quite a bit of time to complete

• I had to type them up first and then write them out. Which even though took a long time, it meant that I had thought about them and overall did quite well.

• You don’t have to fill in every question.

• I found it really helpful to discuss each of my cases over with a doctor that knows that patient before writing them up (also a good opportunity for teaching).

• There is a massive area for you to reflect on what you have learnt. I broke this question up into sections like: What I did well, what I did badly, what I could improve, knowledge I learnt, the patients experience and got really good feedback with that approach.

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SSC

You have to do a presentation.

Look at the markscheme carefully, and make sure you include the vertical themes. There is a point for original thought/research – I took this opportunity to do an audit (which also didn’t take much time!) but I did have to hassle doctors about it.

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Exam

In the portfolio there is a section on Learning Aspects, which form a really good basis for revision. I just went over these (and they also count for a couple of marks towards your portfolio).

Cahill does a mock exam which is helpful (but is easier than the real one)

Overall, the exam is fair and what you have revised will come up. The Obs and Gynae MCQs that David Cahill puts on QMP are really good and there are also lots of MCQs on On Examination website.

So, the biggest tip would be get started on the portfolio immediately and work consistently throughout the whole unit, as the good thing about working consistently in this unit is that when it comes to revision you feel that you know lots already!

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Brief tips from a 5th Year Medic

Kindly written by Salma Aslam, 5th Year Medic (2015)

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ACS:

There is a lot to learn here and it can be overwhelming. The best tip that was given to me was nail 2/4 (I did biochem and haem) and try to go over the other 2 as much as you can.

Anaesthetics is just like emergency medicine so go over ABC, acid-base etc.

RHCN:

Just learn the core lectures.

Impey is a good textbook.

There should be practice questions on blackboard. They were really useful.

Paeds:

There is a a lot of content. As the basics, learn the core Bristol lectures. Then any extra start with the common things. The main systems of the body, the milestones…

Lissauer’s is a great textbook which follows the syllabus.

COMP2:

EPI: make sure you go over the stuff as you do each week as it can be a bit overwhelming if not. You will need to dig your first year book out too.

Care of the elderly: start your clerkings early. The handbook is good but maybe an idea to summarize into your own notes as it is wordy.

GP: the handbook is AMAZING.Learn it all.

DERM: learn the core conditions well eg; acne. Look at lots of pictures.

 

Finally. Don’t panic. There is a lot to learn, but most people get through it.

Just make a list of all you need to cover and by systematic and you will be fine.

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