DYSPHAGIA MNEMONIC (DIFFICULTY SWALLOWING):

• HEENT: Check throat for erythema and exudate
• Neck exam: Check for lymphadenopathy, thyromegaly
• Cardiovascular exam: Auscultation
• Pulmonary exam: Auscultation
• Abdominal exam: Inspection, auscultation, palpation, percussion.
• Skin: check for signs of scleroderma/CREST.

• Esophageal cancer (Dysphagia starts with Solids and progresses to liquids. Hx of chronic alcoholism, smoking & weight loss )
• Achalasia (Dysphasia for BOTH solid and liquids)
• Esophagitis (Pain on swallowing. Immunocompromised “e.g. HIV, Corticosteroids”)
• Systemic Sclerosis (Look for CREST syndrome)
• GERD (Cough at nights, Hoarseness, sore throat)
• Plummer-Vinson syndrome (Iron deficiency anemia, sore throat, craving ice, dirt, clay…)
• Zenker diverticulum (Halitosis, regurgitation)
• Pill-induced esophagitis (e.g. Bisphosphonates)
• Mitral Stenosis (look for an immigrant or a pregnant female)

• CBC
• Serum iron, ferritin, TIBC
• Throat culture
• HIV antibody and viral load, CD4 count
• Chest X-ray
• Barium swallow
• Endoscopy
• Esophageal manometry 
• Chest CT

Abstract and Introduction

• Can I learn this right now in under 5-10 minutes?
• Can I delegate this? (see teamwork below)
• Can I put this off until later?

• Sleep.  All nighters to cram has diminishing returns.  Lack of sleep and fatigue has been compared to a blood alcohol level of at least 0.1% in one Australian study.  Your performance (exam, verbatim recall, etc) and your coordination (procedures, surgery) will be significantly better after a restful sleep. 
• Caffeine.  This is a drug.  Overuse predictably lends oneself to dependence.  The absence of this drug will predictably lead to a state of withdrawal and detract from performance and mental efficiency (headaches, moodiness, etc).  PEARL:  Use sparingly in key moments, caffeine will predictably AUGMENT mental efficiency.  A group of us in medical school never drank coffee on a regular basis.  We leveraged it by drinking it strategically right before an exam.  Our bodies never got accustomed to it and much like an intermittent drug, we felt the augmented mental alacrity when taking it sparingly (n.b. we never experimented with nor recommend "stay awake drugs" such as Provigil).   
• Stop multitasking.  We live in an era where smartphones and tablets are constantly at our fingertips.  Distractibility, attention-deficiency and hyper-activity are real phenomenons that children, young adults and professionals struggle with in this information-accessible culture.  It is an addiction and the metaphorical quick-sand of efficient learning and productivity.  Set predetermined times of studying and breaks to minimize these hazardous distractions.

HOW TO DRINK FROM A FIRE-HOSE WITHOUT DROWNING –
Successful study strategies in medical school courses

Why should I change my study strategies?

• Everyone admitted to a medical school has study strategies successful for an undergraduate informational flow rate – unfortunately, those developed by most pre-meds  are not efficient enough for the fire hose approach of medical school.
• The most fundamental principle of efficient studying  – the best use of your limited time – requires active, not passive learning.
  • Active learning requires making decisions about the material – “Is this important?”, “How is this part organized?”, “Where does this fit into the ‘big picture’?”, “What is the precise definition of this term?”,“Where have I seen this in an earlier lecture?
  • Passive reading of pages of text or “going over” notes (even with a highlighter) and hoping to absorb the information is very inefficient –if you have enough time, it will work and probably did in undergraduate classes, but it usually isn’t adequate for the fire hose.
• Changing a habit isn’t easy, so don’t be surprised if you need to hear or review active strategies multiple times – it takes time to change.
   

What are the fundamentals of active studying?

1. Identifying the important information – answering the eternal question of “what’s important here?”
2. Organizing the information – start with the “big picture” to create a framework that facilitates memorization and access appropriate for differential diagnosis.
3. Memorizing the information – this requires frequent review to keep it available for use!
4. Applying the information to more complex situations – practice questions, quiz questions, clinical applications, etc.

1. Finding the "big picture" by skimming the information before lecture – identifying and memorizing the four or five major topics will keep you on track during lecture.
2. Creating a complete rough draft of the material by annotating the lecturer's slides  – notes emphasizing the lecturer's context are supplemented as needed from other reading materials. Don't rewrite this!
3. Creating summary charts, lists or diagrams that organize the needed material to emphasize patterns that facilitate memorization.
4. Actively memorizing the charts, etc., as they are created, then incorporating quick and frequent review during later study to nail the information down – you'll still need the fundamentals after finals are over.
5. Practicing application using practice or quiz questions during the study process – and not to test yourself just before the exam.

Why find the "big picture" before lecture?

1. The road map. Scan the material to identify the number of major headings and the major subheadings each has, then take just a couple of minutes to memorize those (don't skip this part!). Read the introduction and summary, which emphasize those points.
2. The vocabulary. Scan the material again to note any definitions or equations. Exact definitions are crucial and equations help relate many different factors correctly.

How do I generate my "rough draft" of all this information?

1. Much of the factual information is typically provided in a syllabus or a handout of a lecturer’s Power Point slides, so just annotate these – don’t forget you can use the backs of pages for your notes.
   • Focus on adding context from the lecturer – this requires decision-making and so is active.
   • On a power point graph, note the “point” a graph or chart is making, or clearly label the axes.
   • Emphasize any comments of the lecturer on what is important information vs. what is just “color”.
   • Always note circumstances that indicate when one reflex or response will outweigh another!
2. Number the pages of lecture notes for each subject so that you can easily identify them. You will need those specific page numbers for cross-indexing your notes and references from your summaries.
3. Use abbreviations and develop your own shorthand from them. Never write out the entire name of a macromolecule, gene, etc. after the first time. Use symbols for  words whenever possible and be creative. Keep a list of them for the first quarter or two and be consistent. As they become habit, your speed will improve a lot.

1. Impose the “big picture” on your notes.
   • Add major headings and subheadings within the notes and in the left margin in a different color ink – this reinforces the organization of the lecture. The lecture outline will frequently provide headings if they aren't apparent from the lecture slides.
   • Label each topic in the left margin and circle specific definitions within the notes in a different color – these will be used both for reference and for keying memorization of the material.
   • These processes force you to analyze the material and begin to actually learn it (not just track it); this will speed up integrative summary design, also.
2. Supplement your notes with any additional information from other readings that will be needed to create effective summaries.
   • Use your notes about the lecturer’s emphasis to help decide “what’s important”, and to look for missing information – if the lecturer discussed three abnormal conditions and provided causes for only two, maybe you missed the third.
   • Use the index in the text to direct you to specific topics – don't get caught up passively reading large sections without actively pulling out the facts to incorporate into rough draft.
3. Cross-index your notes between lectures – you won't remember which lecture contained each experiment the weekend before the final.
   • Each time the lecturer mentions something you remember being discussed in an earlier lecture, stop, find the pages in your earlier notes and add the page numbers in both places.
   • This makes it much easier to create summaries that contain the from multiple lectures – which are the most useful summaries!

How do I create organized summaries from my rough draft?

1. What is "necessary" detail? See FAQ on "How do I know what will be on the exam?" or “How do I know how much detail to learn?”
2. Different material lends itself to different types of summaries – simple lists, charts, flow diagrams, or pictures – use whatever combination you prefer.
3. In each case, organize the material to emphasize connections and facilitate memorization.
   • Where possible, create "big picture" organizations that integrate material from multiple lectures.
   • If you're not sure whether to include a specific detail, leave it out and just put in an asterisk in the appropriate spot with the page number from your rough draft for quick reference.
   • Don't recreate the wheel. If you find a good chart in some text orother source, photocopy it and add it to your summaries. Be sure to add any additional information to make it complete or more comprehensive —try a different color ink to make it stand out.
4. Create and organize the headings before you spend any time filling in the actual information.
   • The headings or location within a diagram should reinforce the “big picture” or anatomy or chronological sequence or steps in a physiological process or someaspect of the process.
     • Finalize the organization of the headings for your list or chart, or the spatial organization for a flow chart or diagram before adding in any of the information (this uses up a lot of scrap paper).
     • This requires analysis and integration of the material, which isactive, and aids memorization, since there is a "reason" for the orderor spatial organization.
   • Use a hierarchical approach for headings or spatial organization – no more than five major headings on a list or chart or six major sections on a diagram — more is too hard to remember.
   • If you need more headings or sections, decide how they are related and create subheadings.
   • The same numerical limits apply to subheading – if necessary, go to the next level of subheadings.
   • Make sure your headings (charts/lists) or spatial organization (flow charts, diagrams) provide information due to their sequence or location.
5. Multiple summaries or diagrams are better than one big one.
   • Simple outlines in a syllabus provide a great source for topics that your summaries should cover.
   • Limit the material covered in a single summary to an amount reasonable to memorize, then use multiple summaries to cover the material from different points of view.
   • For complex material, the organization of the headings may not be enough to establish the "big picture"; in these cases, some summaries just focus on the big picture.
   • Don't hesitate to include the same information on different summaries,especially if they are organizing the material from different points ofview or at different levels of detail.

How can I memorize actively and be sure I know the material?

1. Don't put off memorizing material until just before the exam.
   • Of course you will forget much of it after the first time — that's why you need to build repetitions into your study pattern. But if you memorized it actively (see above), you forget the "address" of the information much more than the actual information. So review will move it into long term memory.  If you cram it the night before, you won't remember it a week later, much less the next quarter or the next year.
   • So save the picky (but necessary) details for the night before, but memorize all the concepts and the first couple of levels of detail as you go and review them as you study later material.
2. Memorize the headings first – their order should reinforce useful information like anatomy, time course, etc.
   • First, memorize how many items (e.g., headings) there are
   • Second, memorize the headings themselves – using biological logic, visualization, or mnemonics.
   • Third, memorize the information associated with each heading, starting with just a key word or short phrase, and finally adding the full item.
3. When you think you have memorized any piece of the chart, etc.:
   • Cover the original, and write out the material on a blank piece of paper (don’t be pretty, but don’t cheat!), then throw what you have just written away!!!
   • Look at the original – if you are confident you got it all – great! If there is any question, don’t compare with what you should have thrown away – just memorize it again.
   • This method emphasizes what you don’t know; comparing the new with the old only confirms what you already knew, which  misleads us into thinking we know more than we do.
4. Quizzing each other is good motivation, but beware of subliminal cues used to help answer the questions without mastering the material. Explaining it out loud to yourself is a good start, but you can verbally "hand-wave" around areas you aren't clear on. Always check yourself as above.
5. Frequent review is relatively painless with organized material – and extremely helpful.
   • When an earlier topic or concept is mentioned, stop and review to yourself the relevant summary list – start with how many, then the headings, then the key words, then the concepts or facts.
   • This review actually decreases the time needed to master later lectures, since later material builds on earlier; this also increases exam speed, since answering factual questions will be easier and faster.

How do I prepare for exam questions? 

1. Clarity of definitions or concepts vs. those derived from context.
   • Students often generate their own general concepts or definitions from context – after all, that’s how we learn to speak – but this doesn’t provide enough clarity to analyze and correctly answer the questions.
   • Medical terminology and equations are very precise – being “close enough” often isn’t sufficient.
2. Familiarity with material vs. mastery of the material.
   • “Familiarity” refers to recognizing the logic provided by someone else – as when leaving a good lecture, you can say, “yeah, that made sense.”
   • Mastery of the material requires integration and memorization of sufficient detail that the information can be successfully applied to new situation.
   • Good test questions discriminate between the two!
3. Not having enough time to answer the more difficult applications questions involving multiple steps in feedback loops or multiple related equations.
   • You need a method to approach complex question before you get to the exam.
   • Use examples given in lecture, quiz questions, or other practice questions while you are studying to work out approaches for such questions ahead of time.

Where do I find time for all this?

1. Successful high-volume studying relies on good investment strategies:
   • Finding the “big picture” before lecture is easily put off, but it usually saves more time during creation of the rough draft.
   • Creating summaries takes a lot of time, but it provides the "final draft" from which you study for the final – you won't have time to go back through the origninal notes!
2. There is more time available in a day than you think – use it all.
   • Divide your studying into a series of short tasks – don't wait until you have 2 or 3 hours to study. Use small bits of time while your clothes are drying or while the rice is cooking for dinner for a single task.
   • Use all the "extra" time you can in the early weeks to be caught up in lectures and ahead on papers so there is some slop when it gets really intense.
   • Be VERY careful about "robbing Peter to pay Paul" – it's inevitable, but try to keep it to a minimum. It’s tempting to completely quit keeping up with other classes to study for the upcoming exam, but this is a major trap – that class has a final, too. Usually, skipping class to do a paper or study for an exam ends up costing significantly more time in make-up time in the