Internal Medicine final exam experience

Today, I completed my final exam in Internal Medicine. The exam took place in the 1st Department, which is made up of the subspecialties Pulmonology, Endocrinology, Cardiology, Angiology, Gastroenterology, Infectology, and Haematology.

The exam was scheduled to start at 8 am. We were told to meet at the Clinical and Educational Office (room B227) on the 2nd floor and to bring with us our 8 case reports and Certificate of Completion. One by one the secretary checked our IDs, confirmed we had 8 case reports, took photocopies of our Certificate of Completion, and gave us a paper to take to the practical exam. We were then told to wait outside. Shortly after, the secretary came out and asked for 3 Hungarian students and 3 English students. The six of us followed her downstairs to the Angiology and Endocrinology Departments. Dr Katalin Koltai was our examiner. She gave us each a patient and told us she would be back in 30 minutes to see what we found. 

Practical part

I introduced myself in Hungarian and told the patient I would examine him. He quickly replied, "I will tell you everything." I was surprised that such an elderly, Hungarian man knew English, but this was to my benefit. I took the patient's anamnesis and performed a physical examination. Once I was done, I thanked the patient and went out the hallway to wait for the doctor.

Eventually, the doctor returns and I begin presenting my patient to her. My patient had arrived at the hospital with leg pain that was relieved with rest and got worse with exercise. She stops me and begins asking questions.

Doctor: What kind of pain is this?

Me: Intermittent claudication.

Doctor: What classifications do we use for intermittent claudication?

Me: (thinking)

Doctor: There are two - Fontaine and Rutherford classification.

Me: Oh yes, I remember the Fontaine classification.

Doctor: What category is your patient in?

Me: Well, he said he can only walk 50m before the pain is too much and he has to stop to rest, so 2b?

Doctor: Yes. Tell me some risk factors for peripheral artery disease.

Me: Smoking, alcohol, obesity, dyslipidemia, diabetes, hypertension, age, male gender...

Doctor: Okay, now how do you perform a physical examination for this?

Me: We start by inspecting the legs. We can look for discolouration and swelling. We can palpate the pulses and check for oedema.

Doctor: What else can we see when inspecting the legs?

Me: Hair loss and muscle atrophy.

Doctor: What else should we check?

Me: The temperature.

Doctor: Please show me how to do this.

Me: (I place one hand on each of the legs checking different areas to see that the temperature is the same on both sides)

Doctor: You mentioned pulses. What pulses did you check?

Me: The dorsal pedal artery and the posterior tibial artery.

Doctor: Could you feel them?

Me: No.

Doctor: So what can you do next?

Me: Check for the popliteal arteries and then the femoral arteries.

Doctor: Okay. Did you examine the heart? 

Me: Yes. 

Doctor: Did you hear any murmurs?

Me: No.

Doctor: What arteries do you auscultate to check for murmurs?

Me: The carotid artery and the axilla.

Doctor: What other arteries can you auscultate?

Me: The abdominal aorta, the renal arteries, the iliac and femoral arteries.

Doctor: Okay, now that you have completed the physical examination what other kinds of examinations can you do?

Me: MR Angiography, US, DSA...

Doctor: I was looking for something you can do right here in the room, do you know?

Me: (thinking)

Doctor: Ankle-brachial index.

Me: Yes.

Doctor: Do you know how to perform this?

Me: Yes. You have the patient lie supine position and measure the brachial blood pressure and the ankle blood pressure. The systolic blood pressure of each is compared. If the ratio is between 0.9 and 1.2, it is normal. If it is <0.7, it is diagnostic of peripheral artery disease.

Doctor: Do you know what we say if it is above 1.3?

Me: It is a calcified, non-compressible vessel.

The practical part concluded here. She wrote a 5 on the paper, stamped it and told me to head to the Szentágothai Research Center for my theory exam.

Theory part

When I got there, I found 3 other students sitting. They had all already had their exam and were waiting for the rest of us to complete our exams to receive their grades. The examiner asked that they wait for all the students to be examined first. There was another student in the room and I was next so I sat down to wait. 

Okay, now it's my turn. The examiner was Prof. László Bajnok and I am not sure who the assistant was. 

Prof. Bajnok asks for my paper from the practical part and my 8 case histories. I hand over all the papers and he starts...

Professor: Tell me about anti-diabetics.

Me: Um....Metformin.

Professor: Do you know some groups of drugs?

Me: Gliptins.

Professor: What? I have never heard of such a group.

I was surprised at his response and this is where, I became extremely panicked. I began questioning my knowledge, weren't Gliptins a group of anti-diabetic drugs? Yes, they are but I think the Professor is used to hearing them referred to as DPP-4 inhibitors. Still, in a daze, the Professor continues.

Professor: SGLT-2 inhibitors.

Me: Yes, of course, but I was only thinking of that for heart failure.

Professor: Yes, it's used for heart failure as well.

Professor: Okay, chronic kidney disease. A patient has grade 4 or 5 chronic kidney disease, what are the corresponding values of GFR?

Me: For grade 5, <15  mL/min/1.73m^2 and for grade 4, between 15 and 29 mL/min/1.73m^2.

Professor: What are some anti-diabetic drugs that you can use in chronic kidney disease?

Me: (Again, I went blank)

Professor: Sulfonylureas.

Me: Of course.

Here, the assistant took over for the remainder of the exam.

Assistant: A patient comes in with melena, what do you do?

Me: Check the patient for hypotension and tachycardia.

Assistant: Good. What kind of labs do you do?

Me: Hb, CBC, INR, Platelets...

Assistant: What kind of bleedings are there?

Me: There are two main groups of bleeding. Variceal and non-variceal. Variceal is usually due to portal hypertension and is caused in cirrhotic patients. Non-variceal can be due to things like esophagitis, Mallory-Weiss syndrome, and peptic ulcer disease.

Assistant: What is the first-line treatment of variceal bleeding?

Me: Some kind of vasoconstrictor.

Assistant: Okay what?

I searched my mind for the drug, but it just wasn't coming to me.

Assistant: Terlipressin. What is the treatment of non-variceal bleeding?

Me: Band ligation, laser, electrocoagulation, adrenaline.

Assistant: What is a common cause of peptic ulcer disease?

Me: H. pylori.

Assistant: And in case of gastric ulcer?

Me: NSAIDs.

Assistant: What is the treatment for the eradication of H. pylori?

Me: Well, there are variations of triple and quadruple therapy. For example, PPIs, Clarithromycin and Amoxicillin, or PPIs, Metronidazole, Tetracycline, Amoxicillin.

Assistant: What is common in both?

Me: PPIs.

Assistant: And Bismuth salts.

This was the end of the exam. I thanked them and they asked for me to send in the last student. I walked out and the final student walked in. His exam wasn't too long and then we were all called back into the room. The doctors gave each of us a paper with our names and the grade to look at and return to them.

I ended up with a 3. I was a bit disappointed, but I keep reminding myself that it's better than a fail. I guess I deserved it because I was asked things I should have been able to answer and couldn't. In all fairness, I had roughly 10 days to prepare for this exam and based on the exam experiences of my fellow students, I focused on what I'd been told were the more important topics for the 1st Department. I decided not to cover the Diabetology and Nephrology topics at all, since they are the focus of the 2nd Department, but that did not turn out in my favour. 

During my exam, I was forced to heavily rely on the knowledge I had from my fifth year when took the Diabetology and Nephrology subjects, which I clearly couldn't recall well. Hopefully, I'll have time before the state exam to review these things.

Looking back, the exam was pretty chill. I was extremely anxious and could barely keep any food down the last two days, but my panic was unnecessary because the examiners were calm and friendly.

Another one down, just 1 more to go!