Professional III Exam Preparation: How to Gain Benefit from Ward Round

This article is a expansion of previous article: "Early Preparation for Professional III M.D" [link]

Ward round is not just 'round around the ward' which is commonly done by medical student.

They are not to be blamed as they unable to fully understand the concept behind the ward round, hence preventing them from gaining benefits from it.

If they fully understands it, then it will be a good medium for them to learn effectively so that they will have easy moment during the working day.

The problem arise when the number of medical students increase dramatically. So, the number of student joining the round would be increase as well. This will reduce the effectiveness of learning and student will easily get lost along the way. When the focus is shifted from the patient to their own fantasy world, then nothing will get into their head. In other word, it means useless and wasting of time.

Worst of it is when the attending doctor or specialist will find their presence as annoying. It is not suppose to happen because teaching medical student is part of their job if they are in teaching hospital. But in non teaching hospital, they are not to be blamed for the action. Most of the time, this labeling happen when they find out that medical students are not interested with what they are presenting and discussing. And sometime, they are being disturbed by the action of medical students who chat among themselves about things that are un related to the patient care

In order to gain benefits from ward round, we need to understand what is ward round. In a guideline produce by the Royal College of Physician and Royal College of Nursing in 2012 entitle "Ward rounds in medicine Principles for best practice", they defined ward round as a complex clinical process during which the clinical care of hospital inpatients is reviewed.

Round is usually joined by a team consisting of medical officers or house officers in charge of the patient, specialists, nurses, pharmacists and other related parties including medical students.

The structure of the round usually take part in few steps. The first steps would be the case presentation by the in-charge doctor. He will briefly present the data of patient, initial chief complaint when patient being admitted and the working diagnosis as well as differentials. It is then followed by the progress of the patient, any relevant investigation finding and response towards medication or procedures.

Since time is limited, it has to be done fast, pointing out relevant issue, not missing out the crucial point and well structured.

In the guideline that I point out earlier, it states that ward round process involve few steps and functions.

First is regarding the diagnosis of the patient. as a general rule, the diagnosis has being established after the patient being admitted. However, it was like arranging the puzzle. The more time we take, the puzzle will grow more bigger and we will have more clearer idea. Therefore, the diagnosis may be refined, or changed.

Then, patient's progress is being reviewed back based on the result of available investigations, any changing or additional history and physical examination and patient's observational chart of vital sign, drug chart, any relevant chart like dengue chart, input/output chart, drain chart, GCS chart and many more.

The next step is to make a decision based on the previous two steps. The team will decide on further investigation and options of treatment as well as patient's care.

During this point, the team will identify and triage patient whether he is stable to be discharged, need to escalate or de escalate the treatment, or to be referred to multidisciplinary team for opinion and further management. If patient is found stable to be discharged, then the team will decide on discharge plan; medication, discharge advise and arrangement of follow up.

Apart from that, it is crucial to identify any new threat to the patient, possible harm from the management and pitfall in the management.

This whole process need a lot of effective communication, team work and leadership skills.

So as a medical student, how would you get benefit from this process?

Now that you already understand the anatomy and the purpose of ward round, next is you need to make use of this structure for learning purpose.

You know that time for ward round is limited, so you must know when to interrupt, asking question or keep quiet.

The most crucial step that you should do is to know about the case in the ward. It is a bit easier for the fresh case rather than ‘old’ patient who being treated in ward for quite some times. Because you will always able to see active management by the treating doctor or you can see the response of treatment in that patient. In order to know about the case, you can choose the short cut and the long cut. The short cut is by reading the case note and the long cut is by re clerking the patient.

But, the essential point that you should know is the demographic data of patient, presenting complaint of the patient. What brought the patient to the hospital and clinical finding during the initial presentation. Then you have to digest or understand why certain diagnosis has being made by the attending doctor at that time. Usually it is being formulated after combining the history, physical examination and investigation. Sometime, initial diagnosis consist of more than one differentials. So you should also pay particular attention to the investigations ordered by the doctor in order to narrow done the diagnosis.

Then, look at the medication ordered for the doctor and have a guess why it is being choose. And the next is to know the response of the treatment and other progression. After that, you should do your homework at home. Make sure you read about the case and management of the case so that you would have rough idea about it.

For example; A 10 years old boy presented to the emergency department with complaint of high grade fever associated with chills and rigor, shortness of breath and productive sputum. Initial diagnosis was community acquired pneumonia and you can see that the acute management would be oxygen therapy, prop up the patient, vital sign monitoring or cardiac monitoring, keeping patient nil by mouth with intravenous drip support, medications like broad spectrum antibiotic and analgesia was started. You will take a look at the initial investigation which is Hb 8.4, total white 26.0, platelet 673 and hematocrit 42%. Na+ 120, K+ 4.2, Urea 17.4, Creatinine 220. Chest X rays show right lobar pneumonic changes.

At this step, you should be able to generate few learning points. Differential diagnosis would be pneumonia, pulmonary tuberculosis, meliodosis or he could probably have underlying chronic lung disease but exacerbate by acute infection. Your next learning point would be the active management. You will learn what type of oxygen therapy given to this patient, why he was kept nil by mouth and put on IVD. What is the type of IVD and how to calculate the fluid requirement. What is the abnormality of the blood and radiological examination.

After two days, patient condition is still not improving. Something is not right about this patient. So you would ask yourself. Is this patient in severe sepsis that his kidney function test is not good. Hyponatremia would be due to SIADH from the active lung infection. Why he did not improve? Is the antibiotic working for the patient. Why is that patient still dependent to oxygen.

Then you will find out at the investigation chart that blood C&S come back and shows that patient is resistant to the antibiotic that has being prescribed. So you change the antibiotic and patient is responding well. No more tachypnoeic and was allowed orally. Total white blood count normalized and Hyponatremia resolve. So patient’s active management would be lesser now. Only to complete antibiotic.

Few days later, patient condition suddenly deteriorate. Somehow becoming very tachypnoeic and cannot breath. There was a hyper resonance of the affected lung field and reduce air entry. Somehow, he develop pneumothorax and chest tube was inserted. So you will notice that the doctor will now cover another new problem. One is the pneumonia with sepsis and acute renal failure which is improving but develop pneumothorax. There’s no need to change antibiotic because it’s working. Pneumothorax could be complication. Since chest tube already being inserted, the focus now is to off the chest tube.

Finally after four days, lung already expands back but still there is haziness at the affected lung. Air entry is improving. Chest x rays show no more pneumothorax so the doctor decided to remove the chest tube. But you will be asking yourself, why did the opacities still there? Then you will learn that the consolidative changes on chest x ray will remain at least two weeks.

So now, you will understand about the case, so you will not going to be blur during the round. So you can ask relevant questions to the medical officer or specialist if having free time, for example; 1) what are the criteria that we look for to decide when to insert chest tube and remove it?, 2) is there any scoring system to predict mortality in this patient?, 3) Decision for intubation, 4) markers for infection and so on. Furthermore, you can you this time to clarify your understanding. For example you are not sure whether the chest x ray finding is consolidation or collapse, regime of antibiotic for adult and pediatric pneumonia and so on.

Furthermore, by having reading about the patient, you may also prepare yourself with future questions ask by lecturer. If you can answer it, their impression on you will be better and you will have more teaching session and knowledge from him. For example, like this case; he might be asking you about landmark for chest tube insertion, history and clinical examination to suggest that this patient having pneumonia, how would you monitor patient’s response on antibiotic or medication that has been serving to the patient and also complication of the disease.

Trust me, if you truly able to grab the principles behind this ward round concept, you will learn more effectively. Wards round and reading the patient’s progress will help you to pass the clinical papers.

OSCE pro III series 26

Notes: Modified from OSCE Professional III 2004, station 23. Other kit for this method is called as Pronto test which having similar principles with CLO test.

Questions

1)What is the name of the test that use above kit? (2m)

2)Outline the steps to use the test? (2m)

3)What is the principle of the above test (1m)

4)How to interpreted the test (1m)

5)3 other test to confirm the organism

6)How do you manage the patient with positive results? (4m)

Answers

1)Rapid urease test

2)Steps 

a)Peel back the adhesive cover

b)Place one or more biopsy specimen on the test yellow dote, reseal and press the label over the dot with your finger to squeeze the tissue juice out of specimen.

c)Monitor the result after one minute and up to 60 minutes

3)The basis of the test is the ability of H. pylori to secrete the urease enzyme, which catalyzes the conversion of urea to ammonia and bicarbonate. The alkali product then reacts with the chemical substrate in the test kit and produce positive result.

4)Interpretation of the test

a)Positive result may indicate the presence of H. pylori organism

5)Confirmation of H. pylori

-Gram stain and microscopy of biopsy

-Culture of biopsy

-Serological test for IgG antibody to H. pylori

-Urease breath test (not available in USM)

6)Management of H. pylori induced peptic ulcer disease

a)Giving the triple therapy for one to two weeks consisting of 2 antibiotics and one proton pump inhibitors, for examples

-Tablet Omeprazole 0.8 mg/kg daily (approximately 40 mg In adult)

-Tablet Metronidazole 8mg/kg tds (approximately 400 mg in adult)

-Tablet amoxicillin 10mg/kg tds (approximately 500 mg in adults)

-Or, Metronidazole can be replaced with tab clarithromycin 7.5-15 mg/kg bds.

b)If the triple therapy fails to eradicate the H. pylori, may use quadruple therapy

Omeprazole + Bismuth subsalicylte + Tab. Tetracycline + Metronidazole

c)Withdrawal of any offensive drugs like NSAIDs

d)May add drug for mucosal protective barrier like Sucralfate or antacids like MMT.

Early Preparation for Professional III M.D

To download this article in pdf version, click this [link]

Since my juniors asking me on how to prepare for the coming professional III as they are currently entering final year, i find that it is relevant to share this in this blog so others may benefit from it as well.

It’s also a time convenient for me as i don’t have to reply it personally to everybody. Just click on the link and it’s ready.

Though, i’m not really a best person to give this advice as i’m not truly a maniac in study. My time are full with lot of activities and times for study are quite limited. But insha’allah, i will try to give some tips.

To be honest, i do hope that in the future, there will be a Muslim juniors qualified to sit for viva distinction and awarded with distinction. (sigh! It’s my dream to pursuit it but due to lack of preparation, only manage to get B, but thanks to Allah!)

The key point is to make an early preparation and LOT of practice.

Clinical Part

Long Case 50%

OSCE I & II 20% Total: 100%

Short Cases 30%

Pass > 50

Borderline > 45

Fail <45

a. Short case

Each of you will be assign 3 cases either surgical based or medical based. Those who get surgical based for short case will get medical based for long case.

You will be assigned 10 minutes for each case. You SHOULD spent 5 minutes on examination, 2 minutes for presentation and 3 minutes for discussion with the examiner.

You may choose to do running commentary or present your finding after finish your examination. For medical based especially internal medicine, it is RECOMMENDED that you comment after finish examination.

They are two ways of presenting your finding for short case. One is to conclude first and give detail or you can start from finding and conclude.

Based on my examination, i think this patient have right sided pleural effusion by evidence of reduce chest expansion, reduce breath sound and stony dull on percussion. Other finding in this patient includes (you comment on relevant positive finding from periphery to specific region examination).

Or you can go another way a round.

For my style. I prefer to combine both method and draw a conclusion at the end of examination. I found it more time consuming and you did not miss the finding. During my exam, i was given surgical case which were Non union Right Tibia-Fibula fracture, Graves disease and uterus larger than date. Believe me that i have more than enough time for two earlier cases.

What i did is as follow. You can skip reading this part if find it too long and go to the recommendation section because i’m just blabbering about my exam experience.

First i did an inspection and screen the patient. There i notice that patient is un able to walk and something is not right with her right leg. So i give comment on that and inform the examiner that i want to examine the right leg. So i proceed with specific inspection. (shortening, false joint, scar, external fixator scar, deformity)

Then i did the palpation by comparing both leg. After finish the step, i explain my finding. Next i proceed with movement and after finishing it, i stop and explain my finding to the examiner.

Then i make a conclusion to the examiner that i think the patient was having non union of the right tibia fibula probably secondary to complication of open fracture as evidence of present of external fixator scar, mobile, pseudo joint, non tender, loss of bone continuation and no evidence of infection.

The examiner the stop me and go for a discussion session. he ask me what investigation i want to request. And i go bla bla bla and then he pull out the X-ray, ask me to interpret and how to manage the case. He also ask about definition of non union, type of non union and why non union occurs. After finish with management, he stop asking and we were waiting for the bell to ring.

I did the same thing for the thyroid case. I did quick inspection and told the examiner that i want to examine the neck. Then i specifically inspect the neck and present the finding to examiner. Then i told examiner that i want to proceed with palpation. After palpation, i point up my finding and then i go for auscultation, present the finding and finally percuss the manubrium and present my finding.

Then i make my diagnosis and told the examiner that i would like to examine the periphery to look for sign of hyperthyroidism. The examiner say no need and he just test me on theory about what finding to look in periphery. Then he ask me about advise for the patient (surgery), how to manage the patient in outpatient dept, how to prepare the patient for surgery, complication of surgery and finally the question that i can not answer (difference of primary and secondary hyperthyroidism and prevalence of secondary hyperthyroidism).

For the third case, i did not perform very well because of lack of practice in O&G cases. However i did manage to find finding (more than two pole) and draw conclusion that it was a multiple pregnancy. However the examiner want a diagnosis of Uterus larger than date and we discuss about that. I only manage to reach the differential diagnosis and the bell rang.

Recommendation

- Practice early. Dont wait until study week because there will be a congestion of student who want to examine the patient. It will bring discomfort to patient and waste your time too. So form up your study group and look for patient to examine. (max no of person in study group is 5. The best is 3. But my study group consist of 7 person). The person in charge of finding the patient MUST KNOW the finding and diagnosis of patient. You examine the patient while the other friend act as examiner. Do it in exam format. Other friend will then ask question and you must answer it as you were in exam. To benefit other, allow one more friend to do examination in full format and for patient sake, the other three just appreciate the findings only.

- Many doctors are friendly and helpful enough to help and teach you especially the trainee lecturer. During our time, we make full use of them and be friend with them. They conduct a free class for us during the weekend and also when we have free time during weekday. So, go and befriend with them and arrange extra class with them.

- make use of HRPZ and District posting. Both of them are full with patient with good findings.

- Clinic is a MUST to attend be it surgery, paed, medical, ortho.. they are heavenly place to learn about short cases.

- For medical short case, make sure you finish reading the short case book written by Chu Nee Kong. Trust me it’s REALLY BENEFICIAL.

- For surgical based, i don't have a good book to suggest. But trust me if you go to ward and clinic, it is enough for you to pass because surgery cases are straight forward.

- Practice with your friends at any free time you have to polish you skill and to ensure that your examination is smooth. My study group use to use marker pen to draw finding on skin, use picture to practice describing. At each session, we will be commenting on our study mate performance, what area to improve and also some hot and spicy critics to challenge them to do better.

- I used to use imagination technique and mirror technique for practicing presentation. I use mirror to practice presenting the finding and imagination technique to imagine flow of examination. Close your eye, imagine what you want to examine, follow the step and practice talking. Try it out!

B. Long case

- Take a look at this list and made sure you know in heart about the disease

http://jacknaimsnotes.blogspot.com/2010/04/common-medical-problems-for-clinical.html

also look at your logbook. Some case are nasty as well like lupus nephritis... take a look at past year compilation to familiarize yourself with the common case in exam.

- Always look at guidelines by our ministry of health for management. In exam, they however just want Outline or principle of management.

- Practice, practice and practice. One person will go and clerk the case as if you are in exam. Only spent one hour with patient for clerking, examination and arranging your presentation then spent another 30 mins with your colleague.

With patient:

15-20 min (history)

10 min (detailed physical exam)

10-15 min (arrange presentation)

10 min for thinking bout differential dx, ix, mx

remaining time to clarify history from pt

with friend:

Present for 15 minutes and another 15 minutes for discussion. Your friend will ask question and discuss as you were in exam. To ensure that other benefit it as well. Make sure you write back short history, finding, diagnosis of your patient together with discussion and photocopy it for others.

- like what i mentioned in short case section, approach your lecturer or trainee lecturer or doctor for you to practice presenting case and discuss about management. They know a lot.

- Ideally you should at least clerk one patient per day. That will make you a SUPERB student. But for a lazy person like me, i found out that clerking one patient per week or per two week is enough. The rest, i just flipping over the folder to see the history, ix and management. If i need to clarify something then only i will ask the patient. THIS IS A BAD HABIT if you want to score in your exam. To be honest, i stumble a bit during real exam where my time frame goes hay wire. I miss lot of point during the exam.

- During exam, examiner will ask everything under the sun. Basically the mark for long case are divided as follow

History: 20 mark

Physical examination: 20 mark

Differential diagnosis: 20 mark

Investigation: 20 mark

Management and discussion: 20 mark.

And as a GENERAL they will advance from one level to another level once they satisfactory with you. If you stuck at any part, they will ask you very-very basic question including basic anatomy, physiology, biochemistry or even basic science during matriculation.

Beware of what you called SIMPLE CASE as it may be a killer one for you. One of the examiner told me that not many score on asthma case. I’m one of the example. I got a case of 7 years old Malay boy with mild AEBA secondary to chest infection with underlying mild persistent asthma and atopy. He also have strong family history of atopy, asthma and living in industry area. Other example of simple case that you must know by all of your heart including diabetic foot, diabetes, tuberculosis, pneumonia etc.

Do not create finding or bluff them because each examiner are given template. If you do it then they will make your life miserable.

Tips during presenting the case

- Greet the examiner and ask to sit politely.

- Put your clerking sheet on table in front you and you should sit straight. Do not hold anything with your hand and DO NOT PLAYING with pen, tendon hammer as it is very-very irritating.

-Examiner will ask you whether you have any problem or not during clerking the patient. They will set their standard on you at this time. If you are having serious problem in clerking, they will try to help you in other way.

- Be confident yet humble

- It is best you did not look at the paper at all. Or just minimize looking at the paper. Some examiner wont even ask you to present full history, they just want summary, problem list and positive finding that you find.

- Do not argue with examiner (they are always right)

- Present loudly and clearly. They wont punish you for the broken english as long as the meaning are clear.

- Only one examiner will be dominant but do not forget about second examiner because they will also give you mark. Look at them sometime and offer a smile.

- The time keeper wont give you mark but do not ignore them as they may offer you some tips.

C. OSCE

There will be OSCE I and OSCE II but honesty i think it is just ONE PAPER because you will sit for both of them at the same time with total station are 26 and each station is 5 minutes.

It is considered as a bonus for you to help you pass the clinical part if you can score it. And there is no other way to pass it unless you did a lot of past year questions.

In my blog, i also post some of the OSCE questions and you may find it somewhere. I put the example of the answer for the question but of course you need to double check it. I’m not an expert too.

And, there are a lot of compilation question made by seniors. You can always look for it to make your own answer scheme. When exam is around the corner, you dont have to trouble yourself to read the whole book, just flip trough your own note and it is more than enough.

Apart from that, most of the procedure are common and can be seen in wards or OT like inserting CBD, Ryle’s tube, Digital rectal exam, pap smear, suturing. However, each station has it’s own scheme and what you did in wards may not be true (even though it’s working and practical). Therefore, in order to know the correct step, go to the skill labs and ask help from the staff there. They are willing to teach you the correct step and which aspect will be rewarded points.

Sometimes, during sitting the exam, you will have a thought block. You find it very difficult to recall an answer for the question. My suggestion is, close your eyes and take a deep breath and recite some supplication (doa). Then try to answer it again. insyaALLAH!

If you still unable to recall until the bell rang then forget everything about the station. Just go to the next station and focus. There’s no space and time for you to regret or cry. Sometimes, there will be a moment when you suddenly remember about answer for the past station while answering the current station. Block that thought and focus!

Theory Part

MCQ I&II (100%)

MEQ I & II (100%)

Total: 100%.

MCQ

You need to be really strong to face this paper. Imagine you have part 1 and part two. Each paper have 100 questions (500 respons) and time given are two and half hour. Paper 1 at morning and paper 2 at evening. Really stressful.

Basically for each question, they will be 5 respond. Respond a and b usually basic (anatomy, physio, definition) and very easy. Respond c to e are clinical (management, symptoms, investigation, findings). C is easy, D is moderate and E is DIFFICULT. So basically you will have 3 easy respond, one moderate and one difficult.

The problem with MCQ is it is negative marking and it will be carry forwards. You will get 1 mark for right point and deduce ½ mark for wrong answer. if you did not answer, then no mark will be given or deduce.

For me, basically i will answer the questions in three steps. Step one where i only answer EASY RESPOND from question 1 till end. If i can not answer all respond, i will leave it for second round.

For second round, i answer the moderate respond and try to understand further the question that i left blank and try to answer it..

The final round is for me to decide either i want to answer the remaining respond randomly (tembak) or leave it blank. It’s like a gamble round where i put away the knowledge and depends on my judgment and luck. Here i use logic in answering the questions.

I’ve used this method since first year and in all end posting exam. From what i can say, MCQ is DIFFICULT and i only manage to get B for the MCQ using this method. Probably there’s something lacking in this technique.

Therefore, i suggest you made your own research and ask help from the lecturer regarding the best approach to answer MCQ.

Preparation wise, you need to answer past year questions. You may get it in library or through seniors. Try to answer it. For me, it is best to answer the mcq by putting the correct statement and explanation regarding the question. For example

Regarding neonatal jaundice

a) Conjugated bilirubin is neurotoxic

b) Jaundice within 24 hours of life-physiological jaundice

c) Breast milk jaundice due to decrease production of milk in mother

d) Premature is at risk of severe jaundice

e) Hearing impairment is a complication

Rather than just ticking FFFTT to the question, you made your own notes like

a. False (Unconjugated bilirubin is neurotoxic and can cause death in newborns and lifelong neurologic sequelae in infants who survive (kernicterus))

b. False (Jaundice appearing on day 1 or early day 2 of life is likely to be due to hemolysis and if starting that early, blood group incompatibility between mother and baby is most likely.) **Jaundice on day 1 tends to be pathological and require extensive medical attention.

C. False (Breast milk jaundice is a common cause of prolong jaundice due to unknown factor in breast milk that interfere with bilirubin mechanism. It must be differentiated from breast feeding jaundice which due to inadequate breasts feeding, no early breast feeding or addition of water during feeding.)

D. True (The risk of significant neonatal jaundice is inversely proportional to gestational age)

E. True (sensorineural hearing loss)

Try to do at least 5-10 past year MCQ per day together with the answer. The best way to save time doing MCQ is by doing it together with your study group. Divide the question among yourself and each member must be responsible to do their homework. Jot down the answer nicely in a paper or re-type it and print it to everybody. During your study group, discuss it thoroughly.

In answering MCQ, make sure you use standard textbook reference like Bailey and love (surgery), Neelson (pediatric), CM or Harrison (internal medicine), Ten Teachers (O&G), Appley or principle orthopedic (ortho). If you use internet, do not use Wikipedia. For me, it’s rubbish nearly half of the time. At some time, it could be helpful if you can’t find any other resources.

For me, i made use of google by typing anything i want and search it under header “Books”. Or “Scholar”. You need to type specifically and you will get hundred of standard textbook who offer free page for display regarding the topic that you want. You can jot down the answer from that text book.

Or, make a habit to search the answer through journal. Usually i will use database pubmed, springerlink, elsevier, BMJ and if i’m too lazy then i will just search info in the eMedicine.

It’s a little bit hard but you will be happy with the result. If everybody in your study group do their job with high sense of responsibility, then you can finish one set of question in one day only. Trust me!

MEQ

I dont know about others, but i found that MEQ is the most interesting paper in exam. Because it’s challenging, more practical and need you to apply what you learn. The answer is on the next page (but of course you can not see it).

The pattern of the questions are same every year and you can predict the answer. but of course, you need to practice, practice and practice. Sometimes the answer is similar if you made habit of reading case note in wards.

Try it out. Follow up the case note starting from patient first presentation, see what history did doctor elicit, differential that they put, investigation, outline of management. And see how they change the management once the result come back. It’s quite the same.

Plus, you also need to do past year collection as well to see the pattern of the question and familiarize yourself with it. At the end of the day. It truly worth it.

My last advise

1) Make early preparation.don't wait until study week. During my professional I and II, i usually use study week to rest. But during pro III, i have to struggle so hard because i did not make early preparation. At the end, i just read seniors’ note and summary of the disease and have to struggle until two days before exam.

2) take a good rest and do not worry to much. It will affect your performance. On the first day of exam, i could not sleep at all at night. On the next morning (MEQ paper), i have to bring Coffee each exam session because too sleepy. While others answering continuously, i have to take a break few times to drink coffee.

3) form a study group and ensure all your group mate succeed. The only way to measure whether your study group effective or not is that by having every body pass and not to have top scorer while other fails.

4) Doa banyak-banyak. I use to pray like this. Just for sharing

Ya Allah permudahkanlah aku untuk menuntut ilmuMu, mengingatinya dan menyebarkannya. Bantulah aku untuk menjadi seorang doktor agar aku tidak menjadi fitnah di atas dakwah yang aku lakukan. Buka dan lapangkanlah dadaku untuk menjawab soalan peperiksaan, tenangkan fikiranku dan permudahkanlah aku untuk mendapat idea bagi menjawab soalan exam. Jauhilah aku dari lalai dan cuai semasa menjawabnya. Kurniakanlah examiner yang baik dan berilah aku soalan dan kes-kes yang aku mampu untuk menjawabnya. Ameen!

Hope that will help you. Finally i would like to take this opportunity to thank my study group mate who fight along side me in this very fierce battle. Alhamdulillah we all pass. It is a sweet moment to have everybody pass. Thanks to Dr Adam Al Anas (study group leader), Dr Huzaifah Mat Jan, Dr Hazwan Maznon, Dr Najman Ab. Wahid, Dr Ali Montazerri and Dr Fauzi Wahab.

Thank also to the doctor who provide us (study group) with extra classes and teach us with love.

Internal medicine: Dr Shahidi, Dr Siti Maryam, Dr Nazri Mustaffa, Dr Safarul , Dr

Pediatric: Dr Salmi, Dr Arzuar, AP Noraida.

O&G: Dr Husna, Dr Sham, Dr Shahaniza.

Surgery: Mr Osman (HKB), Dr Siti Rahimah, Dr Huzairi, Dr Amin,

Orthopedic: Dr Muhammad B. Paiman,

A&E: Dr Shaik Farid

Ophthalmology: Dr Azhany Yaacob

ENT: Dr Irfan

And of course other lecturers too.