SCE in Nephrology

Sat for Specialty Certificate Examination (SCE) in Nephrology of RCP (UK), or unofficially regarded as "MRCP Part 4 exam" last month - to be honest it was a tough one, as expected. Exam was very clinical based, and lots of renal biopsy images which are testing the histology knowledge. The details of the exam can be found on RCP website - it's essentially an exam for UK trainees during their penultimate year of subspecialty training, but it's open for oversea candidates as well.

I had an unusual experience I must say. During the day of exam, to my biggest surprise - the test center has encountered technical problem - which it never happened before, and the test has to be delayed to 7.30pm. The test took total of 7 hours - which means, yes, it finished after 2am! That was really my first time ever sitting for an exam across the midnight! And what's more, I had to be on-call the next day!

Anyhow, the crazy experience and weeks of anxiety were over. I have just got the result few days back and I'm glad that I made it. Besides the family support, I'm deeply grateful for the daily registrar teaching by the department - it really helps substantially in my preparation.

So it's time to have a bit of rest now, and perhaps a little celebration. ;)



USMLE Step 1 Prep

Dear readers, this is it - my sharing post on preparation for USMLE Step 1, after receiving quite a number of enqueries for this exam.
Disclaimer: This post is neither a guide nor a suggested study plan. Instead, it is just my own opinion based on past experience. Please take note that I did this exam in '05 (during my 4th year), hence the information may be very much outdated. ;)

The United States Medical Licensing Examination (USMLE) is a multi-part professional exam sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). Medical doctors with an M.D. or M.B.B.S degree are required to pass this examination before being permitted to practice medicine in the United States of America.

There is a huge variety of resources that can aid you for this exam. It is practically impossible to cover everything (in your usual preparation duration of 3-6 months), hence the choice of material is important. I have not tried out all resources, therefore I'll be only sharing those that I've read/ accessed to.

First Aid for USMLE is a must-have - my sincere opinion. Some call it the "Bible", or "Secret-weapon", generally, it is an indispensable tool in your prep. It is very concise, updated (yearly edition) with full of useful tips and mnemonics. The Rapid Review section is its trademark. And I think that, even if you're not sitting for this exam, an undergraduate should also get this book - it's extremely helpful and will strengten your basic science knowledge.

High-Yield Series are an excellent companion for your study prep. I was lucky to have access to the full series (thanks to my university library), and I find the volume on Gross Anatomy, Embryology, Neuroanatomy and Pathology particularly helpful.

Underground Clinical Vignettes (UCV) series are another high-rated study aids. The format is case-based, and designed to be used as a conjunction with a primary review course. I find the volumes on Biochemistry, Behavioral Science & Microbiology (Vol I & II) very helpful.

PreTest has a wide coverage on all the topics, but I think it's quite impossible to study all. I think maybe you should just get the book on Clinical Vignettes - which are all exam-simulated questions with detailed explanations. You can use it as a self-evaluation tool, i.e. a "Mock" examination for yourself just before the real exam - and time yourself!

Apart from books, online Q-bank (Question bank) is almost as popular (and as important). As far as I know, the 2 top-rated Q-banks are:

Kaplan Medical - The questions supplied are well-written, and very similar in style with actual exam. Very time-consuming though, and cost can be a concern especially to undergraduates.

USMLERx - developed by the authors of First Aid - the contents are outstanding, with much cheaper cost.

And lastly, there are many online USMLE forums where you can discuss and share tips among yourselves. Some even share what kind of questions they encountered in the latest paper that they just sat for - hence giving you a rough idea on your coming exam.

I guess that's all of my sharing. I'll probably write another one on prep for Step 2 CK later.

So, good luck and, Happy NEW YEAR! ;)

My PACES Experience (2)

Ya, as promised, this post is about case presentation in PACES exam, in my humble opinion. There are more than plenty of resources on approaching this exam, hence I won't really elaborate too much. I'd just like to share a "format" that I think is "safe" and can be used even when you're in a panic state (Well, at least it works for me).

Let's just take an abdomen station as an example, and renal transplant case is one of the common ones. Upon completing your examination, you turned to the examiner,

1. General physical findings

"Mr Smith (always use patient's name instead of "this gentleman") is comfortable at rest. He has sallow complexion, conjunctival pallor and I noticed that he has finger prick marks and half-and-half nails, with an arteriovenous fistula at his left arm with no recent needling marks. I also noticed that he has gingival hyperplasia as well as fine tremor of his hands."

2. Main System

"...Moving on to his abdomen, there is a scar at right iliac fossa, with a firm mass beneath which is non-tender and dull on percussion. There rest of the abdomen is soft, and there is no hepato or splenomegaly. The kidneys are not ballotable. There is no ascites, and he has no sacral or pedal edema. "

3. Summary (The most important part - score at this point!)

Always go by - Diagnosis -> Etiology -> Function -> Complication (from disease & Rx)

"In summary, Mr.Smith has a transplanted kidney, which is functioning well, for his underlying end-stage renal failure, which most likely was due to diabetic nephropathy. He has features suggesting that he is on immunosuppressive treatment, most likely a calcineurin-inhibitor. He has no signs suggestive of fluid overload or uremic encephalopathy. There is no lymphadenopathy or any suspicious skin lesion."

Easy? Let me break down the important tips for you:

First of all, spot that this is a renal failure patient (The fistula is obviously the tell-tale sign), then switch on your brain engine and the visual survey, looking for:

1. Other signs of renal failure - as mentioned in textbooks, PLUS the evidence of previous dialysis (neck scar of catheter insertion, abdominal scar for peritoneal dialysis, failed fistula at other sites etc);

2. Possible etiology of the renal failure, e.g
- Finger prick mark - diabetes mellitus. If young patient, suspect Type 1 DM and look also for scar of pancreas transplant (usually done together with renal transplant);

- Nephrectomy scar - trauma, hemorrhage from angiomyolipoma, polycystic kidney, obstructive uropathy etc;

- "Gaunt facies" - lipodystrophy due to underlying Mesangiocapillary glomerulonephritis (Easily missed!);

- Autoimmune features - SLE malar rash, scleroderma, or even just skin vitiligo - could be associated with Type 1 DM - think broadly! ;)


3. Graft function status

Clinically by looking (carefully) at recent needling marks, graft tenderness, and signs of fluid overload/ uremic encephalopathy.

4. Side effects of Immunosuppressive treatment

Steroid: Cushingnoid features (long list)
Calcineurin inhibitor: Tremor, gum hypertrophy, hirsutism
And others (azathioprine, MMF, sirolimus etc)

5. Malignancy - Important!

Mentioning lymph node examination and skin lesion shows that you're aware of the risk of malignancy in post-transplant patient - most important ones being skin cancer (SCC/ BCC) and lymphoproliferative disease.

6. Lastly, mention about blood pressure. It shows that you're aware that cardiac death is the most important cause of deaths in post kidney-transplanted patients, which all cardiovascular risks need to be aggressively controlled. Besides, it could also be the etiology of his renal failure (Hypertensive nephropathy) or as a side effect of cyclosporin/ steroid.

So that's about it. Remember, it's a postgraduate exam so you need to look for "more things" so that you can make the impression. A holistic approach will be essential.

Good luck!

Related posts:
My PACES Experience (1)
PACES Case Sharing