PRACTICE STATE EXAM: MY EXPERIENCE

Hey 6th years,

I know some of you are anxious and that’s okay. The last stretch to the end gets really hard but it’s gonna be better than you think. Let’s talk practice state exam.

So this one had me SWEATING. It’s a lottery draw?? And what do you mean we get external examiners? Everyone kept saying it’s just a formality and I don’t need to stress to much about it. As a matter of fact, some people said they didn’t even really read. Just brushed up on a few concepts the day before. Well, I would like to announce: It is not just a formality. I repeat, IT IS NOT JUST A FORMALITY! IT IS VERY POSSIBLE AND NOT THAT DIFFICULT TO FAIL THIS EXAM.

You are going to receive all the details to get to your exam days before- maybe you already have. The exam will be held over the course of a week. The “lottery” is organised by the RO. In the morning, we logged on to a Teams meeting and heard our names called and our assigned departments. I got internal medicine first department. Just my luck right. Once I logged off that call, I opened my ECGs again and familiarised myself with some diagnoses, treatments and such. Went over some more cardiology, haematology and endocrinology. Gastroenterology has never been much of problem for me so I skipped that.

My practical was with Dr Kenyeres in the cardiology department. It was 4 of us he examined, and we were assigned to different patients. We were provided with our patient files and got to interview our patients. I got a 50 year-old male patient, who was hypertensive with new-onset atrial fibrillation. The medical history was unremarkable. The ward was rather busy so we were not really questioned on our examination techniques (I guess they also assume that was tested in the internal medicine final exam). We just had to present the patient case and talk through everything.

When it was my turn, I spoke about the patient, giving both the history and physical exam uninterrupted. Then he started to ask questions.

He asked about the ECG strip in the patient file; I had to describe the rate and rhythm, and abnormalities. I had no issues here. The next question asked was about what to do with a patient like this on arrival. He asked about initial exams and how we diagnose. He asked what lab tests are run and what other exams to do. At some point, I mentioned echocardiography would be important and he asked what type: TTE or TEE, and why.

Up till here, everything was cool. He asked what next after establishing the diagnosis as a.fib. I mentioned we had to check for possible thrombus. Where, he asked. I said the left atrium. Where in the left atrium? I couldn’t answer this… The answer is the left atrial appendage. And with what? The echo. Once again, what kind of echo? TEE for better visualisation. He asked about the two kinds of treatment in heart rhythm disorders. That’s rate and rhythm control.

I’ll list the rest of the questions here for quick viewing.

Questions:

How do we know which to use? I don’t even remember what I said here. I might have mentioned something about being symptomatic. The better answer is haemodynamic instability and inappropriate ventricular rate for rate control. I think for rhythm control, was structural dysfunction like dilated atrium.
What do we do use for rate control?: Beta blockers and (non-DHP) CCBs.
What else? I couldn’t answer and he gave me a hint. (Hint: It was previously commonly used in heart failure). I said digoxin.
When do we not bother with checking for thrombus? We don’t need to check it if patient is already anti-coagulated or if a. fib resolves in 48 hours.

SIMPLE NOTE BC I JUST LEARNED THIS: If you have a patient with a. fib. and no prior cardiovascular history, investigate the patient’s activity in the past few days. Alcohol causes sympathetic hyperactivity and can induce this. A patient may come in with palpitations after a period of binge-drinking. It’s associated with holidays and weekends, especially long-weekends- that sort of thing. For this reason, a. fib. in this context is called holiday heart syndrome. There’s typically no need for anti-arrhythmics in this case as it is self-resolving. Read more here.

What do we use for rhythm control? Flecainide, propafenone, amiodarone.
What non-pharmacological methods can we use? Electric cardioversion.
For a bonus question, he said there was something else. I also did not know this and the answer is pulmonary vein isolation- which makes sense when you remember that the origin of a. fib is the pulmonary veins.

We all got our grades and went upstairs for the oral part.

For the oral exams, we were being examined by a gastroenterologist, a neurologist, a neurosurgeon and a psychiatrist. Everyone went in nervous and came out smiling so it was a bit of a comfort. I was the third to the last to go.

First question was about my thesis. So I walked through it briefly. Many nods of approval.
The gastroenterologist asked all about a. fib again. I just repeated everything. He asked what we check for in lab work. I added that we could check thyroid hormones. We segued into hyperthyroidism.
What do we check in suspected hyperthyroidism? What direction does TSH and T3/fT4 go?
What else can we check? Autoantibodies- list them.
How do we treat? I said metamizole, instead of methimazole. He pointed it out but he understood what I was trying to say. Just be careful to avoid little blunders like this. Also mentioned propylthiouracil and beta blockers.
Neurosurgeon asked how we manage pain in extended spontaneous fracture causing pain. This was a bit confusing for me so I started a whole lecture about the WHO pain ladder. After a good 90 seconds of talking, he goes, “Yes, yes that’s all good but I meant surgically.” It was such a facepalm moment because as the surgeon, OF COURSE HE MEANT SURGICALLY. It didn’t matter much because I still didn’t know what exactly he was looking for. The answer he expected was vertebroplasty, but he didn’t give me a hard time about it (maybe because I demonstrated that I at least knew something about pain management? I’m unsure.)
The neurologist asked about headaches. So I went into them: the classifications and types- primary (migraine, tension headache, cluster headache) and secondary (mass-occupying lesions, haemorrhage, infection, medications, etc, etc). I started to describe them in-depth, starting from migraines and she stopped me.
The psychiatrist was the last and asked how I would treat depression: pharmacotherapy and psychotherapy. I mentioned all the antidepressant groups and drugs. He stopped me midway and went on to psychotherapy. I mentioned music, art, group. He stopped me. They thanked me and asked again about my thesis. Then it was over. I also came out smiling.

Now, I’d like to share some other experiences my peers shared at the time.

PRACTICAL: Internal medicine 2nd department

ORAL: I was examined by a neurology, OBG doc, internist and thoracic surgeon.

Patient had bilateral leg oedema due to liver failure.

I was asked about the physical examination of the liver. I just mentioned that it’s firm, nodular surface, round edge, not painful and did not have to perform it in front of the doctor.

Then we went upstairs and waited for oral.

They called names, and asked the female students to start first. When it was my turn, I went inside and Dr. Kovács gave the other examiners the details about my patient, after which they all asked relevant questions:

Dr. Kovács: What are the most common causes of bilateral leg edema? ANS: HCV, alcoholic liver failure, nephrotic syndrome.
Thoracic surgeon: You have a patient scheduled for elective surgery due to cholelithiasis, and you notice she has liver cirrhosis. Do you perform the surgery? Why or why not? ANS: Do not perform due to an increased risk of coagulopathy as a result of end stage liver failure.
Gynaecologist: Do you know any cause of liver failure in pregnancy? ANS: HELLP syndrome, treated by immediate delivery.
Neurologist: What is a neurological sign of liver failure? ANS: Asterixis tremor and coma due to hepatic encephalopathy.
Neurologist: Is asterixis a true tremor? ANS: No. And then I proceeded to speak about clonus, how it is triggered and the differential diagnosis of tremors.
Neurologist: Back to asterixis, do you know the types of tremor? ANS: Resting, intention, postural, psychogenic, etc.
Neurologist: Do you know any drugs that can also cause tremor? ANS: anti-psychotics, SSRIs, chronic alcohol abuse…
Neurologist: How can you differentiate between drug-induced and Parkinson’s disease tremors? ANS: In Parkinson’s the tremor is asymmetric.

Then they asked what I want to specialise in, where, etc. It was all super fast, not even 10 minutes.

PRACTICAL: Psychiatry department

ORAL: I was examined by a paediatrician, internist, neurologist (Dr. Faludi) and psychiatrist (Dr. Herold).

Patient was diagnosed with borderline personality disorder.

Dr. Herold: List the types of personality disorders. What is the diagnostic criteria for MDD? I couldn’t list everything perfectly but it was totally fine.
Dr Herold: What medications are used for borderline PD and MDD?
Paediatrician: Bacterial meningitis: the most common pathogens, clinical signs, CSF findings.
Internist: Causes of metabolic acidosis. I couldn’t say much but it was okay.
Neurologist: Differences between convulsive syncope and a seizure. Causes of convulsive syncope, as well as the most important cause. I said cardiovascular because it can be an emergency, but he said no it’s the vasovagal syncope caused by emotional stress. I’m not sure why…

Overall, the psych department asked me more detail than expected and other departments less. But missing some details did not affect my grade. It took me about 20 minutes.

PRACTICAL: Surgery department

ORAL: I was examined by a surgeon, psychiatrist, neurologist and cardiology.

Patient had pectus excavatum. We were given information about the patient and there were no separate examination on our physical examination techniques. I only had to present the case in front of the committee and answer some questions regarding the case.

Surgery questions: Give me 3 indications for surgery in this case. What is the best age to perform this surgery? What is the Haller index? What are other procedures are performed for pectus excavatum? Is the metal plate inside the patient permanent? If no, how long do you keep it in for?
Psychiatry questions: List all the anti-depressants that you know. What other drugs can be used different types of depression and co-existing symptoms? What he meant was how do you treat other conditions like insomnia, anxiety, physical symptoms of depression, seasonal depression, etc. What are the side effects of the different antidepressants? Other indications for anti-depressant use. Which drugs can be used alternatively when avoiding certain side effects? Non-pharmacological ways to treat depression.
Neurology questions: What is myasthenia gravis? What antibodies are responsible for the disease? Types of MG and typical symptoms. What are the early symptoms and complaints of an MG patient? What physical examinations can be performed for diagnosis? How can you confirm the diagnosis? How do you treat? Why do we gradually increase the dosage of steroids rather than giving high dose? What immuno-modulatory drugs do we use?
Cardiology questions: What are the symptoms and clinical findings of a myocardial infarct? List some complications of MI. What are the ECG findings?

The exam in itself was not difficult in any way, but there were times where I wasn’t sure if I was doing well or not. Questions were mostly open-ended (e.g., explain, list, etc.) and I ended up dominating most of the conversation. The examiners did not interrupt me while I spoke, nor did they give affirmative nods or comments. The exam took about 15 to 20 minutes in total. After the exam was over, they called out names and announced grades in front of everyone. No one got a grade lower than a 4.

PRACTICAL: Internal medicine 1st department

ORAL: I was examined by a cardiologist (Dr. Kalman), neurologist (Dr. Ács), a radiologist and a gynaecologist (guest specialist).

Patient came to the hospital with symptoms of hyponatraemia induced by indapamide, and shingles. The practical exam was a regular internal medicine examination. I was asked to examine the heart and lungs. She asked about murmurs and where they would radiate to. She asked where I would expect to hear tuberculosis in the lungs. ANS: apex. There’s a German name for it which I didn’t know but apex was accepted. She asked what the lung sounds you would hear in pneumonia, pneumothorax and heart failure were. She asked about spleen examination and how it is described. She asked what side of the abdomen you start palpating from.

Q: Summarize her history.
Q: Patient has hypertension and diabetes. Name the drugs used to treat both.
Q: What drugs can be used in heart patients? I mentioned SGLT2, DPP4, GLP1
Q: Where can it be used? Kidney failure
Q: What do you think why this patient has and why? ANS: Hyponatremia due to diuretics (indapamide)
Q: Name the side effects of thiazides and thiazide-like diuretics.
Q: Differential diagnosis in hyponatremia. I listed vomiting, diarrhoea, burns, SIADH, certain medications.
Q: Treatment of hyponatremia, and what to monitor when correcting.
Q: Complications of hyponatraemia in the patients. ANS: seizures. Patient was brought to ER after grand-mal seizures.
Q: What do you know about varicella? Virus, clinical manifestation, where it lays dormant and what causes it to re-activate, the pattern of skin lesions and why, and the therapy.
Q: We’ve sent her for imaging of all her systemic organs. Why do you think that might be? ANS: malignancy

She was very helpful and gave a lot of hints that were important in the oral exam. It was more of a discussion than an examination.

Cardiology questions: Drugs for heart failure and diabetes. Types of diuretics. List the thiazide-like diuretics.
Gynaecology questions: Hypertension in pregnancy and and gestational diabetes. How to treat. When do we screen? Complications of gestational diabetes and how babies in this situation are managed.
Neurology questions: We talked about thesis. I was asked about ASPECTS scores and when to do thrombolysis and thrombectomy. Neurological complications of hyponatremia.

That’s it guys. Wishing you all the best for this exam and I hope you can rest and enjoy your last month in Pécs before graduation. Take pictures, speak to someone you never spoke to in your 6 years here, make connections and have fun.

Ask any questions you have below.

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