Survival Guide to Third Year

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					Survival Guide to Third Year
         Kellen Choi
           MS IV
            First off,

  You guys are third years!!
              What to do next….
• 3rd year could be a stressful time for all of us. It‟s a big
  transition from learning in a classroom setting, to a real
  life hospital setting.
• Good news: You are not alone!
• Hopefully this LGT could be helpful!
• 3rd year could be a great way to redeem a poor academic
  performance in 1st 2 yrs, or poor step 1 scores.
• Disclaimer: I read and did A LOT of ques on 3rd year.
  You do NOT need to do everything I did to do well.  (my
  classmates did fine without using all the resources I used
   – I just wanted to make a comprehensive PPT so you can pick and
     choose what works best for YOU.
   – I did not intend to stress out anyone with the information stated
     here!  You guys are going to be great!
     Before all your rotations:
• After you take your shelf exam for the
  previous rotation,
  – Relax. Sleep. Have fun.
  – After you recuperate, gather books you need
    for next rotations.
     • Swap books with your classmates and save $$$!
  – Read a corresponding section from First Aid
    for the Wards (or an equivalent book such as
    Boards and Wards) before each rotation so
    you know what to expect.
First Aid for the Wards
               -Good overview of each
               rotation and what to
               expect/how to act.
               -Brief overview of common
               diseases/conditions you‟ll
               see in each rotations

               -Not sufficient coverage of
               pathology, different
               diseases for each rotation
               (especially for the shelf
               -Impossible to fit in a white
               coat 
Boards and Wards
             -Good overview of each
             rotation and most
             commons you‟ll see
             (including pathophys)
             -Diagrams and pictures
             -Easy to carry in your
             white coat

             -Some explanations may
             not be
             -Doesn‟t state what to
             expect/how to act in each
Other Resources (for boards and
                   -I used Step Up to UMLE
                   Step 2 for
                   USMLE II and COMLEX II
                   -I started using it after 3rd year
                   rotations for board studying,
                   but in retrospect, it would have
                   been a good review for
                   -Has GREAT Ob/Gyn section.
                   -Brief Peds section was
                   helpful for boards.
Other Resources book as a second year for
           -I used this
                 clinical aspects we had to know for
                 exams. (e.g. What to do next, treatments
                 -I didn‟t use it for boards studying, but
                 some people liked it for boards and
                 rotations. I looked up certain sections,
                 such as Ob/Gyn during rotations for
                 -It in in a bullets/outline format, and
                 some people thought it was bit “laundry
                 -If you prefer a good overview of each
                 rotations, and would like to use this book
                 for boards as well it may be helpful.
                 -Explains most common
                 diseases/conditions you‟ll see in each
                 rotation. more comprehensive and
                 thorough than FA for Wards.
                 -Does NOT list what to expect for each
                 rotations like FA for the Wards does.
How much studying is enough?
• As much is needed for you to better
  understand what you experienced/saw in
  the hospital that day.
  – Ex) If you see a patient with psychosis during
    the psych rotation, who also has Cushingoid
    features, look up Cushing Disease, PCOS,
    steroid use to see what could have caused
    her psychosis. You’ll learn so much from
    seeing your patients and reading up on
              For All Your Rotations
• I used Case Files, Pretest for all my rotations
  and added additional resource for a reference
    – Step up to Medicine for IM
    – First Aid for Psychiatry Clerkship for Psych etc
• I also used Kaplan Q bank ques that you have
  access to for Step 2 for corresponding
  rotations during my rotation.
    – I didn‟t use Kaplan Q bank for step 2 studying. I
      only used USMLE World for step 2.
• Some people preferred using Blue Prints, NMS for all the rotations. I didn‟t
  use them.
   – Blueprints series are in a textbook form
   – NMS is in an outline form, but way more comprehensive than the First
     Aid and written in a complete sentences.
• I tried to read at least 1-2 hrs/day, or more on
  less busy days on cases that I've seen in the
• I did some ques throughout my rotations,
  especially Kaplan Q bank (timed) since shelf
  exam is 100 ques/2hr 10 min.
  – You'd have to practice on reading fast, and getting
    to the diagnosis/next step quickly.
  – Instead of reading the loooooooong stem and get
    bogged down with every single detailed H/P, try to
    see “what concept are they testing me on?”
     • Will show you an example on this in the few slides.
 Books for Rotations

• OMM:
 – Saverse is all you need! (esp 400 ques at the
   • I read 1-2 ch/day.
   • The chapters are usually very short, and has few
     ques at the end of each chapter.
   • Great book for COMLEX II as well!
 – Cram pages are great for last minute review!
• Peds:
  – First Aid for the Pediatric Clerkship
     • I thought it was a great book! (great differentials and
  – Peds CF and PT were the best from their series!!!
     • CF and PT and FA writers are from the same publisher,
       so their informations overlap.
  – I used BRS Pediatrics to do web assignments.
    Their ques at the end of each chapters along with
    additional 100 ques at the end of the book were
    good for extra practice.
             More on Rotations

• IM:
  – MKSAP 3, 4  They have different ques!
   (MKSAP 3 is NOT just an old edition of
   MKSAP 4)
        • Very similar to the shelf exam.
        • MKSAP 3 is organized based on chief complaints.
          Bit shorter and older ques.
        • MKSAP 4 is organized based on organ systems. Bit
          longer (explanations) and newer ques.
                  More on IM

– Step up to Medicine
  • ~400pgs and dense, but a GREAT RESOURCE!
  • I tried to read up on my patients and use it as a
    reference. I picked a chapter I would like to learn,
    and after I studied certain topics I did the
    corresponding MKSAP ques.
– You are assigned to do ~800 Ques of Kaplan
IM ques.
  • These ques are NOT the same ques from Kaplan Q bank
    que for step 2
  • Your departmental exam is going to be a random 50Q from
    those 800 ques.
  • I thought Kaplan IM ques were harder than the IM shelf.
• FM:
  – Review other rotation materials such as Ob,
    Peds, IM etc
  – Try to read up on topics that are covered in
    weekly quizzes.
  – I read Boards and Wards FM section and
    Step up to Step 2 for weekly quizzes.
  – AAFP board ques were very helpful for
    weekly quizzes and closely resembled the
    shelf exam. You need an ACFP ID to access
    them, but they are free! Just sign up for
    ACFP and you‟ll be able to use them.
      /questions.html (about 800 Q)
• Surgery:
  – Pestana notes: VERY HIGH YIELD!!!
  – NMS Surgery Casebook: Great book! (very helpful for
    online assessments)
  – If you want to go into surgery, Essentials of General
    Surgery (by Peter F. Lawrence) is a great book for a
     • I read up on cases that I‟d have the next day at the OR .
  – Surgerical Recall
     • Great for looking like a superstar during pimping at the
       OR/Wards. I read the cases we had in b/w surgery at the OR
       locker (I had JPS Q4 so I had a LOT of time spent at
       JPS…hehe). You can fit it in your white coat.
• Psych:
  – First Aid for Psychiatric Clerkship
     • BEST FA for the clerkship series!!!
        – I read it 3X  (once to learn, 2nd to review, and 3rd time to
          skim/review last minute before the exam)
        – It‟s only 180 pg. SHORT and Sweet! 
  – Lange Q&A
     • Most closely resembles the real shelf exam (in
       terms of the length of the stem and difficulty).
     • I thought Pretest wasn‟t too accurate on how the
       real exam was like it terms of the length of the
       stem, but it was still a great way to review.
• Oby/gyn:
  – First Aid for Ob/Gyn Clerkship
  – Ob/gyn departmental lectures in the AM are great
    preparation for the shelf.
  – NMS text book:
     • Provided by the ob/gyn department for you to borrow.
     • It was too dense for me, but my other colleague who wants to
       go into Ob/Gyn really liked it. I did ques at the each chapters
       I was weak on.
  – I did hear that Blueprint for Ob/Gyn is a great book. I
    didn‟t personally read it, but I did the last 100 ques at
    the end of the book for practice, since I heard that
    they are high yield for the shelf. Also ACOG boards
    ques you get access to is helpful too.
 Besides studying…what else?
• It‟s difficult to please everyone. Your
  colleagues, interns, residents, attendings,
  and the nursing staff, AND the patients are
  under a lot of stress at times.
• Don‟t take it personally when people get
  upset. Just try to do your best and help
  them out.
• Be a team player! Step up and help out! 
 Quick Rules of Engagement…no
 – Practice on each other!
 – Don‟t get offended if the patients doesn‟t want
   you to treat them (the lowly medical student to
   them). They are just scared. It‟s not you, it‟s
   them. 
 – Have a great stress-free time!
• Peds
  – Check their ears LAST!
    • They LOVE playing with light source. I let them play
      with the otoscope while I examined them, that way
      they hate me less when I check their TM. They
      might still cry, but hey at least I got other parts of
      their body examined without stress.
  – Always carry distracters for the babies
    • I carried bunch of stickers (Winnie-the Pooh, Dora,
      Transformers, whatever is trendy during your
      rotations). Trust me, one sticker can make it or
      break it
• Ob/Gyn
  – Know what your team likes. (or how they want
    things to be done)
    • My team had a specific way to write delivery notes,
      post-partum notes etc. Just ask!
  – Brush up (or learn few phrases) on your
    • Large part of your patients are going to be Spanish-
      speaking. It really helps if you can speak basic
      phrases during the busy morning rounds or at the
    • Spanish for Dummies (like me)
       – Tiene dolor aqui? (do you have pain here? Then you could
         point at other body parts and repeat aqui?)
       – Moviendo bien? : Walking ok? (esp after the C/S)
       – Gracias…muy bien…etc etc (my three years of Spanish
         taking in high school was somewhat helpful  )
• Surgery
  – Sleep when you can, eat when you can, drink water when you
    can…and use the bathroom when you can.
      • I always carried few breakfast bars with me.
      • I left some fruits, water and emergency food in the JPS locker during
        my call days (on ortho and general surgery)
  – I carried pestana notes (printed on 10 fonts, two per page) with
    me during the service.
      • You don‟t have much time to study. Use your down time b/w waiting
        for new admissions or between cases!
  – Youtube is a GREAT resource for seeing procedures before you
    go in next day, or for learning suturing skills.
      • Some doctors let you suture. If you want to go into surgery, this is a
        great opportunity to learn!!
      • I used a towel, a dishwashing sponge to practice suturing. You can
        practice doing two-handed square knots in the OR locker room during
        the down time if you just have any strings with you!
          – Vertical or horizontal mattress, simple interrupted, subcuticular suturing
            are all well used in the OR
               » Running subcuticular suture. One of the best technique I‟ve seen on
• Psych
  – Have an opened mind!
    • This experience will be nothing like what you‟ve
      have had before.
  – Also have sympathetic minds towards the
    patient. They have a debilitating condition and
    are suffering. Some may find it “funny,” but it
    really isn‟t. Be compassionate.
  – Follow the rules.
  – Don‟t ever lose the keys they assigned you.
• FM
  – You will see such variety of patients.
       • Review Peds, Ob, Psych, and IM and surgery.
       • Basically, expect to see little bit of everything!
  – I took my COMLEX PE exam during the family rotation.
    (which I found I passed few days ago! ) I thought FM
    rotation was one of the best way to prepare for the PE
       • I treated the each patient encounter as a practice for PE exam
         cases, as well as to learn from each of them.
           – I‟d knock on the door, walk in and introduce myself and shake
             their hands and started taking notes of their H/P. Then I‟ll wash
             my hands and ask them if I could do a physical exam on them.
             Lastly, I‟d tell them the differential dx and possible tx plans. (Of
             course I‟d let them know that I will have to confirm it with the
             attending first).
  – Take a time to explain to the patient what they may
  – I used First Aid for CS for COMLEX PE and FM
    rotation (for H/P)
• IM
  – Know how your team wants
       • Certain attending/residents want stuff to be done in certain
         ways. Adapt to their style.
  – Listen to your patients. Learn from their H/P.
       • We had a male patient who had Osler-Weber-Rendu
         syndrome (hereditary hemorrhagic telangiectasia). He had
         frequent episodes of severe nosebleeds, bleeding severely
         into his lung to the point that he had to get parts of his lungs
         removed. The patient was always anemic, never got to get
         married, and severely depressed.
       • When I read about these “interesting” cases while studying, I
         was always merely fascinated about them. However, after
         seeing how such diseases can affect an individual, I was
         humbled and realized that these diseases affect REAL
         people and could be extremely debilitating.
       • Sympathize with what the patient is going through. He/she is
         not just an interesting case, but an actual person.
       For All Shelf Exams…
• Do the last 5-6 ques FIRST! (turn to the
  last page of the exam booklet)
  – They are usually short, matching ques. They
    may not necessarily be easy, but it‟s fast
    reading ques you can get out of the way.
          Sample Shelf Ques-Psych
A 24-year-old man is brought to the emergency department by his mother after
barricading himself in his apartment. For 8 months, he has believed that aliens
follow him and control his mind. He was fired from his part-time job 6 months
ago because of unusual behavior. There are no other apparent psychosocial
stressors. His paternal grandmother has major depressive disorder. He does
not use drugs, but his mother states that he frequently drinks beer. There is no
disturbance of mood, sleep, or appetite. Examination shows an extremely
agitated and suspicious patient. There is a 1 x 1-cm abrasion in the right frontal
area. His blood alcohol concentration is 0.5 mg/dL, and serum γ-
    glutamyltransferase (GGT) activity is 40 U/L (N=5–50). Which of the
    following is the most likely diagnosis?

•   (A) Alcohol-induced mood disorder
•   (B) Bipolar disorder, manic
•   (C) Brief psychotic disorder
•   (D) Schizoaffective disorder
•   (E) Schizophrenia, paranoid type
                  Psych Shelf
• Psych Shelf was the first shelf for me. It was one
  of the longest shelf, due to extensive H/P given
  – Make sure you know the criteria for conditions such
    as MDD, Schizophrenia so you can skim through the
    H/P and dx them.
  – I really thought I was reading SAT passages at times.
• Don‟t be afraid to put normal behavior for an
  – If 4 year old thinks there‟s a monster underneath the
    bed, THAT‟s NORMAL!! Who doesn‟t when they are
    5? (I thought there was something underneath my
    bed until 7 yo and I turned out fine…right? hehe)
     • BTW, this concept was on my USMLE Step II this week.
A 72-year-old woman comes to the physician in October
for a routine health maintenance examination. She feels
well and asks about which immunizations she should be
receiving. During her previous routine examination last
year, she received influenza and pneumococcal vaccines.
Two years ago, she received a tetanus vaccine after she cut
herself with the lid of a tin can. She has hypertension
treated with a diuretic. She is active and lives
independently with her husband. She is 157 cm (5 ft 2 in)
tall and weighs 72 kg (160 lb); BMI is 29 kg/m2. Her
temperature is 37°C (98.6°F), pulse is 80/min, respirations
are 20/min, and blood pressure is 130/70 mm Hg. Physical
examination shows no other abnormalities. Which of the
following vaccines is most appropriate to administer at this
(A) Diphtheria-tetanus toxoid
(B) Influenza virus
(C) Measles-mumps-rubella
(D) Pneumococcal
                    FM Shelf
• FM shelf= IM+Ob/gyn+Peds+ Preventive
  – Some people call the FM shelf „a mini step 2‟
  – Great shelf to end with
     • FM was my last shelf exam and it helped me
       review for the step II exams
  – If you have it as a first shelf, don‟t worry! A lot
    of info from step II is a review of step I. You‟ve
    just finished step I, and a lot of the knowledge
    you need to know is there.
     • On a brighter note, since you‟ve seen a preview of
       what to expect for the third year rotations, you are
 A 22-year-old woman with a 10-year history of asthma comes
to the physician because she has had to increase her use of her
albuterol inhaler during the past 6 weeks. Her asthma was
previously well controlled with inhaled glucocorticoids. She
has a 2-year history of generalized anxiety disorder controlled
with fluoxetine and a 5-year history of migraines. The
migraines were well controlled with sumatriptan until 4
months ago when she began to have headaches twice weekly;
propranolol was added to her regimen at that time. She has
been taking an oral contraceptive for the past year. She says
she has been under increased stress at graduate school and in
her personal life during the past 3 months; during this period,
she has been drinking an average of four cups of coffee daily
(compared with her usual one cup daily). She does not drink
alcohol or use illicit drugs. She appears mildly anxious but is
not in respiratory distress. Scattered end-expiratory wheezes
are heard. The remainder of the examination shows no
abnormalities. Which of the following is the most likely cause
of the exacerbation of this patient's asthma?
(A) Fluoxetine therapy
(B) Increased caffeine intake
(C) Oral contraceptive therapy
(D) Propranolol therapy
(E) Sumatriptan therapy
                     IM Shelf
• You saw it right? Yes, the stems are really long
• A lot of „What to do next?‟ ques. Know what
  imaging to order
   – Ex. GS=US (if you suspect that the patient has
     gallstones, do US first)
• Read, do ques, just practicing reading fast and
  sorting out important info.
• IMHO, I thought in terms of the difficulty level.
 A 42-year-old woman, gravida 3, para 3, comes to the
physician because she has not had a menstrual period for 2
months. She reports that she had an episode of spotting 3
weeks ago. She has had no other symptoms. She has no
history of abnormal Pap smears; her last Pap smear was 10
months ago. She is sexually active with her husband and uses
condoms. She is 163 cm (5 ft 4 in) tall and weighs 72 kg
(160 lb); BMI is 28 kg/m2. On physical examination, the
abdomen is nontender to palpation. Pelvic examination shows
a slightly enlarged uterus; there are no palpable adnexal
masses. Which of the following is the most appropriate next
step in management?
(A) Measurement of serum β-hCG concentration
(B) Measurement of serum thyroid-stimulating
hormone concentration
(C) CT scan of the pelvis
(D) Oral contraceptive therapy
            Ob/gyn Shelf
• A lot of STD, vuvular lesions, what to do
  next ques.
• Know when to repeat pap smear, do HPV
  testing or do EMB.
• Know ob specific ques such as when to do
  screening tests, when to do emergency c/s
18. A 3-week-old infant is brought to the physician by his
mother because of a 1-week history of increasingly
frequent vomiting. She says that at first he vomited
occasionally, but now he vomits after every feeding. The
vomitus is nonbilious and consists of breast milk. He has
had fewer wet diapers during the past 2 days. He was born
at term following an uncomplicated pregnancy and initially
fed well. He appears lethargic and dehydrated. A 1 x 2-cm,
firm, mobile, olive-shaped mass is palpated immediately to
the left of the epigastrium. Which of the following is the
most likely diagnosis?
(A) Congenital megacolon (Hirschsprung disease)
(B) Duodenal atresia
(C) Intussusception
(D) Midgut volvulus
(E) Pyloric stenosis
                 Peds Shelf
• If you‟ve just taken step I, you are in a great
• A lot of buzz words, not too many what to do
  next ques. (mostly straight up dx)
• Could be nit picky, and few obscure pediatric
• Review what‟s normal child behavior (and few
  psych stuff like ADHD, Depression etc)
  – Remember, kids who are depressed may present with
    tantrum and acting out.
10. A previously healthy 32-year-old man comes to the
emergency department because of a 3-day history of pain
and swelling of his right knee. Two weeks ago, he injured
his right knee during a touch football game and has had
swelling and bruising for 5 days. One week ago, he
underwent extraction of a molar for severe dental caries. He
is sexually active with one male partner and uses condoms
consistently. HIV antibody testing was negative 3 months
ago. His temperature is 38.6°C (101.5°F), pulse is 100/min,
and blood pressure is 120/60 mm Hg. Examination of the
right knee shows warmth, erythema, and a joint effusion.
Flexion and extension of the right knee are severely limited.
An x-ray of the knee confirms the joint effusion. Which of
the following is the most appropriate next step in diagnosis?
(A) Venous Doppler ultrasonography
(B) Bone scan
(C) MRI of the knee
(D) Arthroscopic exploration of the knee
(E) Arthrocentesis
               Surgery Shelf
    Some people say….
    – Surgery=IM+few surgery stuff
    – I somewhat agree. There a quite a few overlapping
      topics/concepts b/w IM and surgery. If you‟ve taken IM
      before surgery you are in good shape, since you‟d just
      have to review what to do next if all
      medical/conservative treatment fails.
    – Ironically on the surgery shelf a lot of the answers
      were „do NOT do surgery.‟
       • Some say go to the OR is usually never the answer in the
         surgery shelf, unless it‟s life threatening, or resistant
         condition. If possible, avoid surgery and treat with medicine in
         surgery shelf.
• Good mixture of diagnosis and „what to do next‟
    – Know what kind of imaging to do for each conditions,
          More on Surgery Shelf
• ABC‟s first!!!
   – You will get most of the trauma cases right if you get
     this concept. Always check for
      • A: Airway; if the patient is talking to you, their airways is fine. If
        the airway is not patent, INTUBATE!
      • B: Breathing. If their O2 keeps on dropping, or they have a
        severely low pH, INTUBATE!!!
      • C: Check for capillary refill (should be <2) and their oral
        mucosa, VS. Give IV fluid (.9% NS usually)
   ****tq*** If all fails, GO TO THE OR!!!
   (after ABC, and the trauma pt is still having low BP
     and not responsive, just go to the OR!)
  ***tq*** tension pneumothorax is a clinical
  diagnosis if you suspect it, do needle
  decompression(same as thoracotomy) STAT
  instead of trying to do CXR. It can kill the
  patient very fast!
• It was my pleasure working with you guys.
• If you guys ever need anything/or need to
  vent, don‟t hesitate to email me.
• I won‟t be in FW for this semester since
  none of my rotations are here, but I‟ll
  always check my email! 
• Good luck with your future endeavors. I‟ll
  miss yall!!

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