Emergency Medicine Foundation Program

Preamble

Postgraduate Certificate in Family Medicine is a new certification offered by Rawalpindi Medical University, Rawalpindi. This name is well recognized and established for the last many decades worldwide. The learning objectives of this certificate course were designed following a need assessment and a valid syllabus is chosen. It is mandatory to successfully complete all modules of the course to receive the qualification of Postgraduate Certificate in Family Medicine.

This is structured to include lectures and relevant workshops for development of a sound basis for Family Medicine through feasible contact sessions. Rawalpindi Medical University is committed to providing full support for the implementation of this certificate course by allocating necessary resources, providing faculty development, and establishing a monitoring system with an aim to take it to next level to meet with the international standards.

An Expert Committee for Certificate in Family Medicine is framed. The Chairperson of this Advisory Committee is Prof. Muhammad Umar, Vice Chancellor of Rawalpindi Medical University. The members of this committee are as follows:

1. Syed Arshad Sabir, Dean of Community Medicine & Public Health, RMU
2. Ahmad Hasan Ashfaq, Associate Professor of ENT, RMU
3. Rizwana Shahid, Assistant Professor, Community Medicine, RMU
4. Zahid Rafiq, Family Physician, Canada

This advisory committee not only worked responsibly in designing the curriculum of certification in Family Medicine following the identification of needs of the community but also worked meticulously for its launching, implementation and execution.

The Chairperson of Content Approval Committee is Prof. Muhammad Ajmal, who is Dean of ENT & Ophthalmology as well as Chairperson of PGME Committee at RMU.

The untiring efforts of the whole team towards the commencement of this certificate program at Rawalpindi Medical University are worth mentioning. I congratulate them for their commitment and dedication in this regard. I wish that all primary healthcare providers of Pakistan in the near future would be family physicians for a healthier nation.

Dr. Ahmad Hasan Ashfaq                                                        Dr. Rizwana Shahid

MBBS, FCPS (ENT), CHPE                                                                   BSc, MBBS, FCPS (Community Medicine), MHPE

Associate Professor, ENT Department                                            Assistant Professor of Community Medicine

Rawalpindi Medical University, Rawalpindi                                   Assistant Director Department of Medical Education

COURSE CO-DIRECTOR & COORDINATOR                                    Rawalpindi Medical University, Rawalpindi

                                                                                                              COURSE CO-DIRECTOR

Introduction

Family medicine is the medical discipline also known as a general practice, general medical practice, family practice, or primary care. It is a discipline which integrates several medical specialties into a new whole. It is concerned with the holistic approach to patient care in which the individual is seen in his totality and in the context of his family and community. The trainees in family medicine should be appropriately equipped to meet the contemporary and future health needs of individuals and families within their practice community. It is therefore indispensable to get acquisition with knowledge and skills in the major clinical disciplines with appropriate attitude essential to the practice of the specialty.

Family Medicine Practice consists of three Core Areas as depicted below:

Family Physicians should be competent enough to work in a multi-disciplinary context in co-operation with non-professional community health workers in order to respond effectively to the health needs of the population.

There is a need to produce a critical mass of family physicians to bring quality health care closer to the people. Family physicians will provide health maintenance/promotion, disease prevention, basic medical, surgical, paediatric, obstetric and gynecological care within the community.

Dr. Shazia Zeb

MBBS, MPH, DCPS-HCSM, MHPE

Deputy Director, Department of Medical Education

Deputy Director, Quality Enhancement Cell

Rawalpindi Medical University, Rawalpindi

Current Needs & Challenges In Pakistan

The health services in Pakistan still face challenges as even serious patient cannot reach the tertiary care hospitals due to their limited resources. These limitations make Family Medicine even more important as a competent general physician is always needed in such cases to diagnose, treat and refer the patient to the higher facilities where needed. Family medicine itself is a unique specialty, as it takes care of the entire body as one unit with great emphasis on family, health promotion and disease prevention. General physicians getting trained under this certificate course will have broad exposure to the health care of all age groups and substantial experience in the management of diverse pathologic conditions. This includes theoretical and practical exposure in those conditions that are commonly encountered in primary care practice.

It will include a wide range of acute and chronic medical conditions of Family Medicine, preventive health care and ethical issues. Moreover, discussion on the cost and benefits of diagnostic tests, procedures and therapies will also be an integral part of this certificate course. This course will provide an educational experience to the general physicians deemed necessary to provide comprehensive and coordinated care to the patients. Training will be conducted under the supervision of the trained faculty members of the respective specialties that will be monitored by the Department of Medical Education of RMU.

 Course Objectives

On completion of certification in Family Medicine, the participants should be able to:

1. Practice competently the field of Family Medicine at the levels of primary care, family care and institutional care
2. Describe the principles of health promotion and disease prevention as integrated components of the general and complete healthcare system
3. Practice family medicine with a prime focus on the needs of our patients
4. Work in multi-disciplinary context in cooperation with non-professional community health workers in order to respond effectively to people’s healthcare needs
5. Undertake diagnosis and initial management of all medical and surgical emergencies up to transportation of the patients to the hospital
6. Apply the best part of their knowledge, advice and good communication skills
7. Manage commonly occurring community / public health problems
8. Refer the cases to secondary and tertiary healthcare facilities, recognizing the limitations of Primary Health Care (PHC)
9. Provide leadership to the other health workers for effective service delivery
10. Coordinate health care services and programs
11. Manage health resources and institutions for efficient service delivery
12. Prevent locally endemic diseases and promote health
13. Provide evidence based management of the diseases

 Specifications

Course Schedule

Time Table

SEMESTER-I

• Basic Principles of Family Medicine
  • Cardiovascular
  • Infectious Diseases & Radiology
  • Gastroenterology & Liver
  • Respiratory
  • Musculoskeletal & Dermatology

Module 1 –  Basic Principles Of Family Medicine

Module Incharge: Prof. Syed Arshad Sabir

Module Faculty: Prof. Naeem Akhtar, Dr. Rizwana Shahid, Dr. Afifa Kalsoom, Dr. Mahjabeen Qureshi, Dr. Arsalan Manzoor, Dr. Naeem Liaquat, Dr. Saima Ambreen, Dr. Madeeha Nazar

MODULE 1 –  BASIC PRINCIPLES OF FAMILY MEDICINE

MODULE 1 –  BASIC PRINCIPLES OF FAMILY MEDICINE

MODULE 1 –  BASIC PRINCIPLES OF FAMILY MEDICINE

Case Scenario

Topic:  Prevention and Screening of diseases

Department of Public health is operational in the city with a goal to reduce the burden of disease. A Public health team included a General Physician who is running a clinic in a highly populated area of the city to “estimate” the prevalence of diabetes in that area. They select a screening test which was highly sensitive but moderately specific. Tests were offered to all “eligible “patients and also to their attendants visiting that clinic. There was high “yield” of the applied test but a good number of screens in whom test results were eventually found negative were annoyed with their doctor.

1. What would be the preventable burden of diseases in the regional context?
2. How diseases can be controlled & prevented? Elaborate in terms of levels of prevention.
3. What is role of screening in disease prevention & control?
4. What are the problems associated with a highly sensitive screening test giving false positive results and highly specific but with false negative tests results?
5. What are common screen able conditions and their screening tests?

Topic:  Infection Control

1. A diabetic patient was admitted with gangrenous foot in surgical ward of Holy Family Hospital, Rawalpindi. He was discharged on 3^rd post-operative day. Now he comes to visit emergency of the hospital with high grade fever along with blood and pus oozing out of his wound. Being an infection control officer what guidelines about PPE would you give to the treating doctor?

2. A patient is admitted in emergency with high grade fever, profuse hematemesis, melena and disorientation. He is suspected to have Ebola virus infection. What infection control measures will you follow being a doctor?

MODULE 2 –  CARDIOVASCULAR

Module Incharge: Prof. Imran Saeed Ali

Module Faculty: Prof. Imran Saeed Ali, Dr. Naima Shahzadi, Dr. Atif Shahzad

MODULE 2 – CARDIOVASCULAR

MODULE 2 – CARDIOVASCULAR

Case Scenario

Topic: Chest Pain

1. 45 yrs old gentleman an office executive with very long working hours, smoker, presented in your clinic with complaints of episodes of dizzy spells, which have worsened over the last one week. On examination he has BMI of 25. Pulse 88beats/min regular, BP 150/90mmHg. He is suffering from emotional stress these days as his younger brother died three weeks ago with Acute Extensive Anterior wall MI as a complication of Diabetes. He does not give history of breathlessness as such, however, on probing he admits to experiencing un-proportional breathlessness on effort with palpitation and retrosternal burning, especially when he has to walk at a faster pace or has sometimes to climb the stairs to his office when the lift is not operational.

How will you proceed?

2. 36yrs old lady known diabetic for the last 5yrs presents to your clinic for routine management for diabetes. Her BP is maintained on 140/90 for the last few visits without medication.

How will you proceed?

Topic: Hypertension

1. 60 year old male with no pre-morbids presented to you with severe headache.
   His blood pressure is 180/100mmHg. Blood random sugar is 250mg/dl. Pulse rate is 90 beats per min. Respiratory rate is 12 breaths per min. Systemic examination is unremarkable.
   How will you proceed?
2. A 40 year old male known hypertensive and smoker presented to you for follow up.

His BMI is 28kg/m2, Blood pressure is 140/100, pulse rate is 80 beats per min regular. He is afebrile. Systemic examination is unremarkable.

 How will you manage the case?

3. A 30 year old pregnant female with gestational age of 26 weeks presented to you with headache and vertigo.

On vital examination her blood pressure is 160/100 in left arm in supine position. , Blood pressure is 140/100; pulse rate is 80 beats per min regular. Afebrile Systemic examination is unremarkable.
How will you manage her?

MODULE 2 – CARDIOVASCULAR

Case Scenario

Topic: Heart failure

1. A 60 year male known diabetic and hypertensive diagnosed case of ischemic dilated cardiomyopathy presented to you with complaints of shortness of breath NYHA IV along with 2 days history of burning micturation, urgency and increased frequency.

He is taking tab Aspirin 75mg OD, tab spiromide 40mg OD, tab lisinopril 5mg OD and

 tab Bisoprolol 2.5mg OD.

On examination his BP is 90/60 mmHg, pulse rate is 112/min regular respiratory rate is 28/min, temperature is 100 F.

He has bilateral fine crepts at bases. His first and second heart sounds are of normal intensity

How will you proceed?

2. A 65 year old male known hypertensive, dilated cardiomyopathy with EF 30 – 35% presented to you with complaints of shortness of breath NYHA IV, orthopnea, paroxysmal nocturnal dyspnea and bilateral pedal edema. He is poor compliant with treatment.
   
   His BP is 85/60 mmHg, pulse rate is 106/min respiratory rate is 28/min, temperature is 98.6 F.
   
   He has bilateral fine crepts at bases. His first and second heart sounds are of normal intensity

His ECG shows bigeminy.

How will you investigate and proceed?

MODULE 3 –  INFECTIOUS DISEASES & RADIOLOGY

Module Incharge: Dr. Mujeeb Khan

Module Faculty: Dr. Mujeeb Khan, Dr. Nasir Khan / Dr. Maria Khaliq

Case Scenario

Topic: Imaging of chest diseases

A 55 years old male patient presented with history of off and on cough and fever for the last 3 weeks. Chet X-ray showed scattered areas of air space shadows involving bilateral lung fields.

Topic: Imaging of bone diseases

12 years old limping child presented with pain in his left thigh referring to the knee joint. X-ray showed lytic lesions in distal end of the femur.

Topic: Dengue

26 year old male, Rashid, Labourer by profession, resident of Tarnol, Islamabad, with no comorbids, presented to the Emergency Department with a 4 day history of a sudden onset high grade intermittent fever, documented at 104 F. The fever is associated with severe headache, pain behind his eyes, severe muscle aches and a severe backache. He also complains of severe generalized abdominal pain and vomiting upon any kind of oral intake and hasn’t passed urine since early in the day. On Examination his mucosal membranes are dry and there are multiple bruises on his arms and legs. Vitals are as follows: BP 100/70, Pulse 84, Temp 101F, Respiratory rate 22. CBC showed WBC 1.7, Hb 12.4, Hct 45.5, and Platelets 24. On Ultrasound there was a streak of peri-cholecystic fluid.

Topic: Malaria

43 year old female, Shahnaz, hypertensive house wife and mother of 3, from Rawalpindi, presented to the ER with a 12 days history of recurrent fever spikes followed by rigors and chills with profuse sweating. She also complains of a severe headache, myalgia, fatigue, loose stools and dark colored urine. On Examination there is jaundice of the eyes. Ultrasound reports an enlarged spleen. CBC shows WBC 10.3, Hb 9.6, Hct 27.6, Platelets 68, Total Bilirubin 4.6, Urea 24, Creatinine 1.1, Na 132, K 4.9, Cl 110.

MODULE 3 – INFECTIOUS DISEASES & RADIOLOGY

        Case Scenario

Topic: H1N1 Influenza

67 year old Male, Khalid, Hypertensive and Diabetic, Resident of Karachi, having just returned from Umrah, presented to the Accident & Emergency department with a 3 day history of a high grade continuous fever with chills associated with a nonproductive cough with a headache and severe body aches along with a 1 day history of sudden onset SOB and severe chest discomfort. There was no associated flu like symptoms. O2 Saturation was 82% on room air. Blood Tests showed WBC 3.2 Hb 12.6 Platelets 149, Total Bilirubin 1.4, Urea 45 Creatinine 2.1 CRP 23. Chest X-ray showed diffuse patchy infiltration. 

MODULE 4 – GASTROENTEROLOGY & LIVER

Module Incharge: Dr. Tayyab Saeed Akhtar

Module Faculty: Prof. Muhammad Umar, Prof. Hamama-tul-Bushar Khaar, Dr. Tanveer, Dr. Tayyab Saeed Akhtar, Dr. Aqsa  

MODULE 4 – GASTROENTEROLOGY & LIVER

MODULE 4 – GASTROENTEROLOGY & LIVER

Case Scenario

Topic: Liver Diseases

Patient is 19 years of age who presented to her physician’s office with mild jaundice. The patient reports being in good health until a week before, at which time she began having flu-like symptoms of headache, low-grade fever, nausea, loss of appetite, and malaise. She self-treated the fever with acetaminophen. The symptoms persisted. Upon awakening this morning, she noticed that her eyes were yellow. She indicated that her urine has been darker than usual and she has been experiencing joint pain for the last three days. She also acknowledged that her stools have been lighter than usual. She therefore contacted her physician’s office. Her labs are : Hematocrit (Hct) 40%, Hemoglobin (Hgb) 13.3mg/dl, White blood cell count 6200 cell/ul , Aspartate aminotransferase (AST) 323 Units/L, Alanine aminotransferase (ALT) 358 Units/L, Total bilirubin 3.7 mg/dL, HBsAg negative, HBsAb Positive, Alkaline phosphatase (ALP) 85 Units/mL, Prothrombin time (PT) 11.6 seconds, Albumin 3.8 mg/dL, Glucose 84 mg/dL.

1. What is differential diagnosis?
2. How will you further investigate the case?
3. How will you manage this patient?

Topic:  Upper GI bleeding

A 35 years old female, presenting to Emergency Department with history of hematemesis of fresh blood twice in the past 3 hours. She feels light headedness and her blood pressure is 80/50, her pulse is 110/minute. She gives history of ibuprofen for 2 weeks now for back pain. Examination reveals that she appears anxious and somewhat restless. Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity is noted. Abdominal examination is unremarkable. Her labs are :  Hemoglobin 9gm/dL, Hematocrit 27%, MCV 90. WBC 13,000/mm. PT/PTT – normal. BUN 45mg/dL, Creatinine 1.0 mg/dL. Chest X-ray – normal.

1. What is the initial management?
2. What could be the causes of UGI bleed in this patient?
3. How will you assess the prognosis and mortality of UGI bleed patients?

MODULE 4 – GASTROENTEROLOGY & LIVER

Case Scenario

Topic: Lower GI bleeding

29 years old Female reported several months of diarrhea and general malaise. She has had 6 – 8 loose to watery stools daily. She denies hematochezia or melena.  She endorses increased fatigue and lethargy. Her appetite had been poor and she thought she had lost 10-12 lb.  She also reports intermittent joint pains, particularly in her knees. She denies fever, but has had night sweats on several occasions. She denies palpitations, increased hunger or tremor. On examination temperature was 37.8^oC. Abdominal examination notable for right lumbar quadrant tenderness. Examination of her knees was normal. Stool tests: WBC seen, positive FOBT, no ova, cysts or parasites, negative bacterial cultures.

Labs:  Hct 32, WBC 13.5, ESR 38, CRP 21.2

1. What is differential diagnosis?
2. How will you further investigate this patient?
3. How will you manage this patient?
4. What are extra intestinal manifestations of Irritable Bowel Disease?

MODULE 5 – RESPIRATORY

Module Incharge: Prof. Muhammad Khurram

Module Faculty: Prof. Muhammad Khurram, Dr. Atta Ur Rahman Saeed

MODULE 5 – RESPIRATORY

Case Scenario

Topic: Lower Respiratory Tract Infections (LRTI)

A 17 years old boy presented with complaint of episodic shortness of breath and wheeze. Family history of allergic asthma is present. Clinical diagnosis of clinical asthma was made. What investigation you will do to confirm?

1. CXR
2. PEF monitoring
3. sputum for eosinophil
4. spirometry with reversibility
5. methacoline challenge test

Topic:  COPD

A 65 years old male diagnosed as a case of group A COPD on the basis of history and investigation. What will be the first treatment option?

1. single bronchodilator
2. combination of bronchodilators
3. inhaled steroid
4. inhaled steroid and bronchodilator
5. inhaled steroid and Roflumilast

Topic: TB

A 50 YEARS old female, known case of uncontrolled diabetes mellitus presented with complaint of fever and productive cough for 10 days. Patient was prescribed 5 days course of co-amoxiclav for LRTI but no improvement. CXR was done showing infiltrates in right upper zone. Clinical / radiological diagnosis of PTB was made. What will be the first investigation to be done?

1. CBC and ESR
2. Sputum for AFB smear
3. sputum for gene expert MTB
4. SPUTUM FOR AFB culture
5. HRCT chest

MODULE 6 – MUSCULO-SKELETAL & DERMATOLOGY

Module Incharge: Prof. Muhammad Idrees Anwar

Module Faculty: Dr. Harris Bela , Dr. Husnain Khan, Dr. Shawana Sharif, Dr. Shumaila Mumtaz

MODULE 6 – MUSCULO-SKELETAL & DERMATOLOGY

MODULE 6 – MUSCULO-SKELETAL & DERMATOLOGY

Case Scenario

Topic: Musculo-skeletal pain

1. Approach to inflammatory Arthritis)

A 30-years old lady who delivered her first baby six months back presented with complaint of pain, swelling and early morning stiffness (lasting till mid-day) involving small joints of her hands and feet for last 3 months. At first glance at your primary care clinic, you have noticed that she has multiple swollen hand joints.

1. What relevant questions would you like to ask her in history and how will you proceed with her examination?
2. How will you plan her workup to reach the diagnosis?
3. What is your initial management plan and when will you refer the patient to specialist clinic?

1. Psoriatic Arthritis

A 30 years old gentleman with presented with asymmetrical polyarthritis along with pitting and ridging of nails and scaly skin lesions. What is the most likely diagnosis?

1. Gout
2. Rheumatoid arthritis
3. Psoriatic arthritis
4. Fibromyalgia
5. Ankylosing spondylitis

Topic: Common Skin Problems

1. Approach to a patient with a scaly erythematous plaque

A 35 year old male, laborer by profession presents to you with a single itch plaque on dorsal surface of right forearm for 2 weeks.  There is no previous history of any skin lesion. On examination, well demarcated scaly erythematous annular plaque 2×2cm on dorsal surface of right forearm was observed.

1. What are the questions you would like to ask in history?
2. What is your clinical diagnosis?
3. Which investigations you would like to do?
4. How will you treat him?
5. When will you refer this patient to a dermatologist?

MODULE 6 – MUSCULO-SKELETAL & DERMATOLOGY

Case Scenario

1. Approach to a patient with acne

A 35 year old female presented with 1 month history of pimples on face. On examination, 2 papules, 3 pustules and 1 comedone were found on cheeks and bridge of nose.

1. What questions you would like to ask in history?
2. How will you grade acne?
3. How will you treat her?
4. When will you refer her to a dermatologist?

1. Approach to a patient with melasma

A 25 year old married female presented with brown patches on cheeks for 6 months. On examination, symmetrical brown patches were present on apples of both cheeks.

1. What questions you will ask in history?
2. How will you grade it?
3. How will you treat it?
4. When will you consider referring to a dermatologist?

1. Approach to a patient with scabies

A 15 year old boy presented with 1 week history of skin lesions with nocturnal itching. On examination, excoriated papules were found on hands, feet and trunk.

1. Which questions are important in history?
2. Which specific lesions will you look for and where?
3. How will you treat him?
4. When will you consider referring to a dermatologist?

MODULE 6 – MUSCULO-SKELETAL & DERMATOLOGY

Case Scenario

Topic: Wounds & Burns

1. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?

1. Superficial

1. Partial-thickness superficial

1. Partial-thickness deep

1. Full thickness

2. The newly admitted patient has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized

1. Superficial

1. Partial-thickness superficial

1. Partial-thickness deep

1. Full thickness

3. Which type of fluid should be given as fluid resuscitation during the emergent phase of burn recovery?
4. Colloids
5. Crystalloids
6. Fresh-frozen plasma
7. Packed red blood cells
8. All requires hospitalization except
   a) 5% Burns in children
   b) 10% Scald in females
   c) Electrocution
   d) 15% Deep burns in adults
9. A 40 years old male presented in emergency with 30% mix thickness burn. His body weight is 80
10. How much fluid you will infuse in first 8 hours?
11. a) 3600 ml
12. b) 4600 ml
13. c) 6600 ml
14. d) 9600 ml

SEMESTER-II

• Neurology & Urology
• Endocrinology & Mental Health
• ENT & Eye
• General Clinical Skills & Emergency Case Management
• Gynaecology / Obstetrics & Pathology
• Paediatrics

MODULE 7 – NEUROLOGY & UROLOGY

Module Incharge: Prof. Nadeem Akhtar

Module Faculty: Prof. Nadeem Akhtar, Dr. Meher Bano, Dr. Zein-El-Amir, Dr. Sharjil Wahid, Dr. Masroor Hussain Malik

MODULE 7 – NEUROLOGY & UROLOGY

MODULE 7 – NEUROLOGY & UROLOGY

MODULE 7 – NEUROLOGY & UROLOGY

Case Scenario

Topic: CNS Tuberculosis & Stroke

1. 84 year old woman began to experience gait difficulty and vertigo since yesterday. She also complains that objects seemed to be jumping around. She is non-hypertensive non diabetic with no history of smoking and substances abuse. O/E she is well oriented and alert, her vitals are normal, fundoscopy is normal. Cranial nerves examination seems to be normal except for dysarthria, nystagmus on horizontal eye movements worsened on lateral gaze to either side. Finger nose test and heel shin test were impaired on left side. Gait was impossible with inability to even stand unassisted. What is the most likely diagnosis?
2. 38 year old man brought to emergency room with history of sudden onset of severe thunder clap headache 06 hours back followed by loss of consciousness, Examination revealed severe neck stiffness with bilateral papilledema and sub-hyloid hemorrhages on fundoscopy.
3. A young patient presents in emergency with sudden onset weakness of right half of body with difficulty in speech. O/E power in right upper limb is 2/5, right lower limb 4/5 with motor aphasia.

Topic: Head Injury

A 25 years old male patient, falls from a height of 20 feet. He is brought to the emergency room in a semi-conscious state. First aid was given on the spot and has a bandage applied to his head. What steps should be followed by the treating doctor to successfully manage this patient.

MODULE 7 – NEUROLOGY & UROLOGY

Case Scenario

  Topic: Renal / Ureteric Colic, Acute / Chronic Urinary Retention

1. A 38-year-old lady patient presents to the urology clinic with off-and-on flank pain. She is afebrile and has no other co-morbids. On physical examination, she has slight flank tenderness. Routine laboratory investigations reveal Hemoglobin 12 g/dl, serum creatinine 0.9 mg/dl and multiple RBCs in urine. On Plain CT abdomen, there is a 25mm stone in the left kidney. What is the best course of management?
2. A 25-year-old woman presents to the emergency department with acute right lower quadrant pain. On examination, she is febrile having fever of 38.5C, with chills and rigors, and has tenderness in the right flank. Her WBC count is 18000/mm³. Routine laboratory investigations show hemoglobin 12.5 g/dl, serum creatinine 1.2 mg/dl and numerous RBCs in urine. On non-contrast enhanced CT, a 12 mm mid-ureteric stone is found, causing hydro-nephroureter. What is the best course of management for this patient?
3. A 30-year-old man was involved in a road traffic accident and presented to the emergency department. During resuscitation his vitals were BP 90/60mmg, pulse 110/ minute regular, respiration 26/minute, afebrile, pupillary reflexes intact. Chest showed bilateral air entry. Abdomen was tender and there was a bruise in the flank. A contrast enhanced abdominal CT showed 1.5cm laceration of the kidney. There is slight hematuria in the Foley catheter. What is the best management for this condition?
4. A 55-year-old man presented to urology clinic with painless gross hematuria and clots. He is a chronic smoker. He has a long history of sero-sanguinous umbilical discharge. Laboratory investigations show Hemoglobin 10.5 g/dl, Creatinine 1.1 mg/dl and multiple RBCs on urinalysis. Flexible cystoscopy was done and showed a bladder tumor, which was subsequently resected. What is the most likely histology?

MODULE 8 – ENDOCRINOLOGY & MENTAL HEALTH

Module Incharge: Prof. Muhammad Khurram

Module Faculty: Prof. Muhammad Khurram, Prof. Muhammad Ali Khalid, Prof. Asad Tameezuddin Nizami, Dr. Noreeen Chaudhry, Dr. Naveed Sarwar

MODULE 8 – ENDOCRINOLOGY & MENTAL HEALTH

MODULE 8 – ENDOCRINOLOGY & MENTAL HEALTH

MODULE 8 – ENDOCRINOLOGY & MENTAL HEALTH

MODULE 8 – ENDOCRINOLOGY & MENTAL HEALTH

MODULE 8 – ENDOCRINOLOGY & MENTAL HEALTH

Case Scenario

Topic: Diabetes Mellitus

1. A 50 years old obese diabetic lady presents in diabetic clinic with complaint of hyperglycemia. She is taking metformin and sitagliptin in maximum dose. Her average BSR is 150 to 200mg/dl. What will be the next management step to control her blood sugar levels?
2. Sulfonylureas
3. GLP-1 agonist
4. Pioglitazone
5. Basal insulin
6. A diabetic patient on basal bolus regime presents with complaint of fasting hyperglycemia.

In order to control BSF what will be appropriate next management step.

1. Stop basal insulin
2. Check BSR at 3 AM
3. Stop Pre-dinner bolus insulin
4. Add oral hypoglycemic at night

Topic: Renal Failure

A 50 year old male presents to hospital with complaints of fever, vomiting (2 to 3 episodes/day) and diarrohea( 4 to 5 episodes) for the last two days.  Vomitus was about a cup, no blood. Stools are watery containing mucus but no blood. He feels that his urine output has decreased and he felt dizzy upon standing in the morning. He has history of hypertension and dyslipidemia for which he has been regularly taking furosemide, enalpril and simvastatin. Clinically he is mildly dry, with a BP 105/73, HR 90 and with urine output of 35ml/hr. Labs show Sodium 132 mEq/l, Potassium 5.0 mEq/l, Urea 24  mmol/l ,Creatinine 390 µmol/l.

Which one of the following is the best management option?

1. Switch to high dose IV furosemide, stop enalapril, and give IV fluids to maintain urine output, daily bloods
2. Stop furosemide, stop enalapril, add in dopamine and maintain adequate hydration to maintain urine output, daily bloods
3. Stop furosemide, stop enalapril, adequate fluids to maintain urine output, daily bloods
4. Continue furosemide, stop enalapril, high dose corticosteroids and continue adequate fluids to maintain urine output, daily bloods
5. Any other medication?

MODULE 8 – ENDOCRINOLOGY & MENTAL HEALTH

Case Scenario

Topic: Thyroid Disorders

1. A 60-year-old woman presented with cold intolerance, fatigue, somnolence, heaviness in the chest, breathlessness on exertion, along with weight gain. She also noticed complaints of constipation and gradual abdominal distension for 6 months. She also suffers from muscle stiffness on and off.

    On examination, the patient looks obese, pale, with dry skin, dry hairs and hoarseness

Investigation:

• Full Blood Count Hb-9.2g/dL, WBC –7,700/cmm, poly – 65%,lympho – 30%,                                                                                          mono – 5% , ESR -50min in 1^st
• MCV 102 fl (normal 76 to 96).
• PBF Macrocytic and normochromic.
• Chest X-ray Cardiomegaly with clear margin.
• Cholesterol 9mmol/L (normal 3.7 to 7.8).
• Triglyceride 4mmol/L (normal 0.8 to 2.1)
• CPK 560 IU/L (normal 10 to 79)

1. What is the likely diagnosis?
2. Mention one investigation to confirm your diagnosis.

2. A house wife of aged 49 years was hospitalized following an attack of unconsciousness. According to the relative’s statement, the patient was feeling unwell with loss of appetite, lack of interest, constipation and weight gain for the last 9 months. No significant past medical history.

      On examination, BP-170/105 mm Hg, pulse – 54/min, no response to painful stimulation. No neck rigidity, no Kerning’s sign. Plantar – extensor on both sides. Heart and lungs – normal.

Investigation:

• Full blood Count Hb – 8.7g/dL, WBC – 19300/cmm, poly – 83%, lympho – 17%, platelets – 2,35,000/cmm, ESR – 41 mm in 1^st
• PBF Macrocytosis and normochromic.
• Serum bilirubin 29mmol/L (normal 2 to 17)
• SGPT 41 IU/L (normal 5 to 40)
• Alkaline phosphatase 91 IU/L (normal 20 to 100)
• Serum electrolytes Sodium 119mmol/L., Potassium  1 mmol/L.

                                                                        Chloride 90mmol/L. Bicarbonate 24mmol/L.

• RBS 9mmol/L.
• Urea 3mmol/L (normal 2.5 to 6.7)
• Creatinine 110µmol/L (normal 50 to 120).
• ECG Heart rate 54/min and T- inversion in V1 to V6.
• Chest X-Ray
• CT scan of brain

1. What is your diagnosis?
2. Suggest two immediate investigations.

MODULE 8 – ENDOCRINOLOGY & MENTAL HEALTH

Case Scenario

Topic: Thyroid Disorders

3. A 25 – year- old lady teacher is referred form an obstetrician for medical consultation. Following delivery of a baby 3 months back, the patient is complaining of weakness, tiredness on mild exertion and loss of appetite. She has been breastfeeding normally and her son is well. She has one daughter, delivered by lower uterine cesarean section (LUCS).

     On examination, she is mildly anemic, edema- mild, pulse – 110/min, BP- 145/70 mm Hg. Thyroid – mildly enlarged. Cardiovascular, respiratory and abdominal examinations are normal.

Investigation:

• Full Blood Count Hb – 10.0g/dL, WBC – 8200/cmm poly – 70%,                                                                           lympho30%,
• RBS 2mmol/L.
• Serum electrolytes Sodium 141mmol/L, Chloride 102mmol/L.
• Potassium 3.8mmol/L.
• Chest x-ray Normal
• Serum Creatinine 100 µmol/L (normal 55 to 125)
• Serum Urea 3 mmol/L (2.5 to 6.6)
• FT₃ 5 pmol/L (normal 1.2 to 3.1).
• FT₄ 172pmol/L (normal 65 to 145).
• TSH                                                 6 mIU/L       (normal 0.8 to 3.6).

1. What is the most likely diagnosis?
2. What treatment will you give?

4. A 27yrs old pregnant lady with family history of thyroid disorders presents in first trimester presents to you for the screening of thyroid function tests, on her TFTS Report shows TSH, T3, T4 are raised.

 What will be the next step of management?

• Wait and Repeat TFTS in 2^nd trimester
• Get FT3 FT4 done.
• Start with the treatment immediately?

MODULE 8 – ENDOCRINOLOGY & MENTAL HEALTH

Case Scenario

Topic: Depression & Suicide

A 48 years old lady presents to your clinic with self-inflicted superficial tentative cuts on her neck. She was rescued by her family while trying to slit her throat alone in a room. On being questioned, she reported that her life felt like a burden. She had low mood, frequent weeping spells, and would find no pleasure in daily activities for the past 2 months after the death of her 20 years old son in a road traffic accident. She would dwell on her past mistakes and feel hopeless about the future. Her sleep and appetite were also reduced. On further questioning, it was found that she had had 3 similar episodes in the past 15 years. She is hypertensive and diabetic since the last 5 years.

Topic: Schizophrenia

A 20 years old man is brought to your clinic forcefully by his family. He has a 8 months’ history of hearing voices commenting on his activities, which he believes are electromagnetic signals that he receives of his neighbors reporting his activities to intelligence agencies. To keep these neighbors from spying on him, he has isolated himself in his room and put extra locks on all the doors and windows. He becomes aggressive if anyone from his family communicates with his neighbors. Lately, he stopped eating and taking care of his self since the last 1 month and the family had to forcefully bring him to the doctor.

Topic: Dementia

A 72 years old man is brought to your clinic by his family with complaints of increasing irritability and suspiciousness. They also report that for the past 3 years, he has memory impairment which keeps getting worse. He cannot go out of the house alone as he gets lost on the way, and sometimes wears mismatching clothes. When he cannot find one of his belongings at home, he gets aggressive and claims that thieves have stolen his stuff. Since he was now becoming unmanageable at home, the family has brought him to the doctor for advice.  

MODULE 9 – ENT & EYE

Module Incharge: Prof. Muhammad Ajmal

Module Faculty: Prof. Ali Raza, Prof. Fuad Ahmed Niazi, Dr. Ahmed Hasan Ashfaq, Dr. Maria Waqas

MODULE 9 – ENT & EYE

Case Scenario

Topic: Nasal Obstruction

A 23 years old boy presents in the ENT OPD with the complaint of nasal obstruction for the last 5 years. The nasal obstruction is intermittent and alternate from side to side. There is a history of frequent sneezing and nasal discharge, headache and post nasal drip. On examination, there is a gross deflection of the nasal septum on the left side. Throat examination reveals granules on the posterior pharyngeal wall. How you will proceed with the management of this patient?

Topic:  Ear Discharge

A 40 years old woman presents to ENT OPD with the complaints of left-sided ear discharge for the last 7 years. She also complained of decreased hearing from the left ear. On examination, there is muco-purulent left sided ear discharge with a central tympanic membrane perforation. On nasal examination, there is bilateral marked inferior turbinate hypertrophy with discharge in both nasal cavities. How you will manage this case?

Topic:  Recurrent Sore Throat

A 20 years old male presents in the ENT OPD with the complaint of recurrent sore throat for the last 7 years. During the episode of sore throat he experiences a low grade fever, change of voice, nasal stuffiness and decreased hearing. On examination there are bilateral hypertrophied tonsils and deviated nasal septum. Patient has been asked by many general physicians to undergo tonsillectomy. How you will manage this case and will council him regarding the nature of his illness?

MODULE 9 – ENT & EYE

Case Scenario

Topic: Gradual Decrease of Vision

A 59 years old male presented in Eye OPD with complaint of gradual decrease of vision.

1. What is the differential diagnosis?
2. How will you manage the case?

Topic: Red Eye

A 26 years old male presented to OPD with complaint of redness and discharge from right eye.

1. What are the important points in the history that need to be asked?
2. Enlist differential diagnosis.
3. Describe management plan.

Topic: Lid Mass

A 35 years old female presented in OPD with complaint of growth on right upper eyelid since 1 month.

1. What are the important points in the history that need to be asked?
2. Enlist differential diagnosis.
3. Describe management plan.

MODULE 10 – GENERAL CLINICAL SKILLS & EMERGENCY CASE MANAGEMENT

Module Incharge: Dr. Usman Qureshi, Dr. Abdul Naeem

Module Faculty: Prof. Muhammad Idrees Anwar, Prof. Muhammad Khurram, Prof. Imran Saeed Ali

MODULE 11 –  GYNAECOLOGY / OBSTETRICS & PATHOLOGY

Module Incharge: Prof. Shagufta Sial

Module Faculty: Prof. Shagufta Sial, Dr. Humera Noreen, Prof. Naeem Akhtar, Dr. Kiran Fatima

MODULE 11 – GYNAECOLOGY / OBSTETRICS & PATHOLOGY

Case Scenario

Topic: Hypertension in pregnancy

1. A 26 years old woman at 26 weeks of gestation presents to your clinic for antenatal checkup. On examination her B.P is 145/95mmHg. Which laboratory investigation is most appropriate to advice?
2. A 20 years old woman, Primigravida at 32 weeks of gestation presented to you with complaint of severe headache. On examination edema ++, B.P 180/120, proteinuria ++ on routine urine examination. How will you manage her?
3. A 35 years old woman G₅P₄ now at 36 weeks of gestation presents to your clinic to show her laboratory investigations. On CBC her Hb is 10.6 g/dl, urine R/E shows proteins 2+. On examination her B.P is 160/110mm Hg, edema ++. She is otherwise asymptomatic. How will you manage her?

Topic: Diabetes in Pregnancy

1. A 28 years old woman with type I DM on treatment comes to your clinic. She wants pre pregnancy counseling as she is told by some friend that diabetes can cause anomalies in fetus. What will you advise her?
2. 28 years old Primigravida at 24 weeks of gestation comes to your clinic for first time. She has positive family history for DM. Her BMI was 30kg/m². She did not have any other risk factor. Which investigation would you advise her?

Topic: Anaemia in Pregnancy

A 25 years old female presents at 24weeks of gestation with generalized weakness and shortening of breath for 2 weeks. Her blood complete count shows Hb 6gm/dl. How will you manage her?

MODULE 11 – GYNAECOLOGY / OBSTETRICS & PATHOLOGY

Case Scenario

Topic: Safe use of drugs in Pregnancy

1. A 22 years old Primigravida at 10 weeks of gestation presents with complaint of burning micturation and dysuria. On routine urine examination shows 25-30 puss cells. Which drug is safe for her to treat UTI?
2. A 25 years old healthy female presents to your clinic at 8 weeks of gestation. She has no history of any co morbid and currently not taking any medication. She is very anxious about baby’s health and wants you to prescribe her supplements. Which supplement will you prescribe her at this gestational age?
3. A 22 years old woman, primigravida at 20 weeks of gestation. She is known epileptic for 10 years. In addition to her anti-convulsing treatment she is taking iron supplements and 400 mcg/day of folic acid. What will you advise her?

MODULE 12 – PAEDIATRICS

Module Incharge: Prof. Rai Muhammad Asghar

Module Faculty: Prof. Rai Muhammad Asghar, Dr. Mudassar Sharif, Dr. Mudassar Gondal, Dr. Naeem Liaquat

MODULE 12 – PAEDIATRICS

MODULE 12 – PAEDIATRICS

Case Scenario

Topic: Common Paediatric Surgical Problems

1. A 2 days old baby presented in Accident & Emergency department with failure to pass meconium, gross abdominal distension and bilious vomiting. On examination, Pulse was 120 beats/minute; respiratory rate was 52 breaths/minute. Abdomen was distended and anus was patent. There is also antenatal history of Polyhydramnios.

• What is most likely diagnosis?
• What are differential diagnoses?
• How will you manage this child?

2. A 5 years old boy presented in OPD with recurrent abdominal pain. There is history of off and on bleeding per rectum. Child is pale looking having hemoglobin of 6.7 gm/dl. Ultrasound abdomen was unremarkable

• What is a differential diagnosis?
• How to investigate the patient?
• Outline management plan?

3. A 9 years old boy presented in Accident & Emergency department with sudden onset of pain in scrotum from last 6 hours. O/E right hemiscrotum was red, swollen and tender. Clinical examination of opposite side was unremarkable.

• What is differential diagnosis?
• How will you investigate this child?
• How will you manage this patient?

ASSESSMENT

The Candidates will be formatively assessed in this course.

Total 3 formative assessments will be carried out, each after every four modules.

This assessment will comprise of the following strategies:

• One correct MCQs / one best MCQs
• SEQs
• OSCE
• TOACS

Certification

Certificate of Family Medicine Certificate course will be issued to the qualifying candidates by Rawalpindi Medical University on securing 60% marks in formative assessment. The final result of the candidates will be average of all 3 formative assessments.

References

• Essentials of Family Medicine (6^th edition) by Philip et al.
• Swanson’s Family Medicine review (8^th edition) by Alfred et al.
• Current diagnosis and treatment of Family medicine (4^th edition) by Tanet et al.

SELF DIRECTED LEARNING (SDL) RESOURCES

1. SOPs for communicable disease response and control

http://www.pshealth.punjab.gov.pk/Home/Sops_guidelines

2. Guidelines for Crimean-Congo Hemorrhagic fever

http://www.pshealth.punjab.gov.pk/Home/Sops_guidelines

3. Guidelines for Measles

http://www.pshealth.punjab.gov.pk/Home/Sops_guidelines

4. Guidelines for Pandemic Influenza (H1N1)

http://www.pshealth.punjab.gov.pk/Home/Sops_guidelines

5. Guidelines for Zika virus disease

http://www.pshealth.punjab.gov.pk/Home/Sops_guidelines

6. Guidelines for prevention of Hepatitis A & E
7. Guidelines for the management of Gastroenteritis
8. Guidelines for the management of Dengue hemorrhagic fever
9. Guidelines for the management of respiratory tract infections

MANDATORY TEXTBOOKS

• Oxford Handbook of Clinical Medicine (10^th Edition)
• Current Medical Diagnosis & Treatment (2019)

Links For Audiovisual Self-Directed Learning

1. How to pass the nasogastric tube

https://www.youtube.com/watch?v=1OakmxZDa5c

2. How to perform phlebotomy

https://www.youtube.com/watch?v=s-vTzQkUQd8

3. How to pass a Foleys catheter

https://www.youtube.com/watch?v=2iLPfCAMgZs

4. How to check arterial blood gases

https://www.youtube.com/watch?v=0BSv4iN8T2E

5. How to check urine for ketones

https://www.youtube.com/watch?v=JaGXDyX876A

6. How to interpret ECG

https://www.youtube.com/watch?v=EmmjwgwHkO0

7. How to pass an intravenous cannula

https://www.youtube.com/watch?v=aXJZSYOh6dU

8. How to use the Otoscope

https://www.youtube.com/watch?v=FqSCfqoCNiI

9. How to use the ophthalmoscope

https://www.youtube.com/watch?v=NE_epHjNpfo

10. How to apply a different splints for fractures

https://www.youtube.com/watch?v=pGxxKH4wSqs

https://www.youtube.com/watch?v=iNPy_ClgT9Q

https://www.youtube.com/watch?v=8jnCDQDzbAc

https://www.youtube.com/watch?v=WXA5Ha3P7PE

https://www.youtube.com/watch?v=150jl5ChCb8

https://www.youtube.com/watch?v=bw__wWpHg-E

https://www.youtube.com/watch?v=pK01AfxMBtk

List Of Abbreviations

List Of Abbreviations