LOG BOOK

MD GENERAL MEDICINE
Liaquat University of Medical &
Health Sciences, Jamshoro

PROF. DR. IMRAN ALI SHAIKH

Chairman,
Department of Medicine
Liaquat University of Medical &
Health Sciences, Jamshoro
 BIO-DATA OF THE CANDIDATE

Student’s Name
Pass Port size
First Name : photo of the
Surname : Student to be
affixed by the
Father’s Name : HOD
Date of Birth :

MBBS Degree
Year of Passing :
College :
University :

Internship
Period :
Hospital / Institution :
Medical Reg: No :
Permanent Address :
Address for communication
With Telephone No. :

Local Guardian
Name, Address &
Phone No. :

Signature: __________ Signature of HOD: __________

STATUTES
1. Nomenclature of the Proposed Course

The name of degree program shall be MD Internal Medicine.

This name is well recognized and established for the last many decades worldwide.

2. Course Title: MD Internal Medicine

3. Departments of Internal Medicine LUMHS.

4. Duration of Course the duration of MD Internal Medicine course shall be four (4) years

(First year in Part I and next three years in Part II) with structured training in a recognized department
under the guidance of an approved supervisor

The course is structured in two parts:

Part I is structured for the 1st calendar years. The candidate shall undertake training in Basic Medical
Sciences, Behavioral Sciences, Biostatistics & Research Methodology. At the end of first year the
examination shall be held in Basic Medical Sciences. The clinical training in fundamental concepts of
Internal Medicine shall start from the 1st day of enrollment.

Part II is structured for 2nd, 3rd and 4th calendar years although the clinical training shall be started from
1st year. It has two components:

1. Clinical training in Internal Medicine

2. 2. Research and thesis writing The candidate shall undergo clinical training to achieve
educational objectives of MD Internal Medicine (knowledge & skills) along with rotations in
relevant fields. Research component and thesis writing shall be completed over the four years
duration of the course. Candidate will spend total time equivalent to one calendar year for
research during the training.
3. Registration and Enrollment
• Total number of students enrolled for the course must not exceed 2 per supervisor/year.
• The maximum number of trainees that can be attached with a supervisor at a given point of
time (inclusive of trainees in all years/phases of MD training), must not exceed beds to trainee
ratio at the approved teaching site shall be at least 5 beds per trainee.
4. The University will approve supervisors for MD courses.
5. Candidates selected for the courses after their enrollment at the relevant institutions shall be
registered with LUMHS as per prescribed Registration Regulations.
AIMS AND OBJECTIVES OF THE COURSE

AIM
The aim of four years MD program in Internal Medicine is to train residents to acquire the
competency of a specialist in the field of Internal Medicine so that they can become good
teachers, researchers and clinicians in their specialty after completion of their training.
GENERAL OBJECTIVES MD
Internal Medicine training should enable a resident in:
1. History and Physical Examination – The effective acquisition of a medical history and the
performance of a comprehensive physical examination in patients with acute and chronic
internal medicine diseases necessitating hospital admission.
2. Case Presentations - Students are expected to effectively record an initial history and physical
examination and follow-up notes as well as deliver comprehensive oral presentations to their
team members based on these written documents.
3. Test Interpretation – Basic understanding of routine laboratory and ancillary tests including
complete blood count, chemistry panels, ECG, chest x-rays, pulmonary function tests, and body
fluid cell counts. In addition, students will properly understand the necessity of incorporating
sensitivity, specificity, pre-test probability and Bayes laws/theorem in the ordering of individual
tests in the context of evaluating patients’ signs and symptoms.
4. Diagnostic Decision Making – The formulation of a differential diagnosis with up-to-date
scientific evidence and clinical judgment using history and physical examination data and the
development of a prioritized problem list to select tests and make effective therapeutic
decisions.
5.Therapeutic Decision Making – This objective includes assessing the risks, benefits, and costs
of varying, effective treatment options; involving the patient in decision-making via open
discussion; selecting drugs from within classes; and the design of basic treatment programs and
using critical pathways when appropriate.
6. Core Internal Medicine Concepts – The development of a basic understanding of core
Internal Medicine concepts.
7. Communication and Relationships with Patients and Colleagues- The establishment of
rapport with patients by identifying important psychosocial issues and providing patient-
centered care through specific medical treatment as well as education. In addition, the
development of effective communication skills demonstrating respect, compassion and integrity
in working relationships with fellow students, house staff, faculty, nurses, and ancillary
personnel. In each of these components, sensitivity to racial and cultural diversity should be
demonstrated.
8. Bioethics of Patient Care – The development of a functional understanding of informed
consent, advanced directives, and the physician-patient relationship.
9. Self-directed Learning – The identification of key information resources and the utilization of
the medical literature to expand one’s knowledge base and to search for answers to medical
problems. They will keep abreast of the current literature and be able to integrate it to clinical
practice.
 10. Preventive Medicine – The promotion of health via adult immunizations, periodic health
screening, and risk factor assessment and modification.
11. Research and Scientific Knowledge - Practice evidence-based learning with reference to
research and scientific knowledge pertaining to their discipline through comprehensive training
in Research Methodology.

SPECIFIC LEARNING OUTCOMES:

Following competencies will be expected from a resident completing MD Internal Medicine
training; Inpatient Services: All residents will have rotations in intensive care, coronary care,
emergency medicine, general medical wards, general medicine, ambulatory experiences etc.
The required knowledge and skills pertaining to the ambulatory based training in following areas
shall be demonstrated;
1. Cardiology
2. Pulmonary Medicine
3. Endocrinology
4. Rheumatology
5. Gastroenterology & Hepatology 6. Nephrology
7. Haematological Disorders
8. Psychiatry
9. Inpatient Oncology & Palliative Care Services
10. Neurology
11. Dermatology
12. Critical Care Medicine
13. Geriatric Medicine
14. Reproductive Health
15. Evidence-based Medicine and Clinical Epidemiology
16. Health Screening and Prevention
17. Infectious Diseases

1. Procedural Skills:
Residents must be able to perform competently all medical and invasive procedures essential
for the practice of general internal medicine. This includes technical proficiency in taking
informed consent, performing by using appropriate indications, contraindications,
interpretations of findings and evaluating the results and handling the complications of the
related procedures mentioned in the syllabus.

2. Additional Procedural Skills:

Residents should be instructed in additional procedural skills that will be determined by the
training environment, residents' practice expectations, the availability of skilled teaching faculty,
and privilege delineation.
Interpretative skills: Residents should be able to interpret basic as well as advanced laboratory
data as related to the disorder/disease.
Electives: In addition, the resident will elect rotations in a variety of electives including nutrition,
nuclear medicine or any of the medicine subspecialty consultative services or clinics. They may
choose electives from each medicine subspecialty and from offerings of other departments.
Residents may also select electives at other institutions if the parent department does not offer
the experiences they want.
Research: All residents in the categorical program are required to complete an academic
outcomes-based research project during their training. This project can consist of original bench
top laboratory research, clinical research or a combination of both. The research work shall be
compiled in the form of a thesis which is to be submitted for evaluation by each resident before
end of the training. The designated Faculty will organize and mentor the residents through the
process, as well as journal clubs to teach critical appraisal of the literature.
Outpatient Experiences: Residents should demonstrate expertise in diagnosis and management
of patients in acute care clinics and longitudinal clinic and gain experience in Dermatology,
Geriatrics, Clinical immunology and allergy, Endocrinology, Gastroenterology, Hematology-
Oncology, Neurology, Nephrology, Pulmonology, Rheumatology etc.

Interdisciplinary Medicine: Adolescent Medicine, Dermatology, Emergency Medicine, General

Surgery, Gynecology, Neurology, Occupational Medicine, Ophthalmology, Orthopedics and
Sports Medicine, Otolaryngology, Physical Medicine and Rehabilitation, Urology. Community
Practice: Residents experience the practice of medicine in a non-academic, non-teaching
hospital setting. The rotation may be used to try out a practice that the resident later joins, to
learn the needs of referring physicians or to decide on a future career path.

Part-II Examination
1. All candidates admitted in MD Internal Medicine course shall appear in Part-II (clinical)
examination at the end of structured training program (at the end of fourth year) and having
passed the Part-I examination.
2. The examination shall be held on biannual basis.
3. The candidate who fails to pass the examination within 7 years of enrollment shall be
dropped from the course.
4. To be eligible to appear in Part-II examination the candidate must submit;
i. Duly filled, prescribed Admission Form to the Controller of Examinations duly
recommended by the Principal/Head of the Institution in which he/she is enrolled;
ii. A certificate by the Principal/Head of the Institution, that the candidate has attended at
least 75% of the lectures, seminars, practical/clinical demonstrations
iii. Original Log Book complete in all respect and duly signed by the Supervisor (for Oral &
practical/clinical Examination)
iv. Certificates of having passed the Part-I examination
v. Examination fee as prescribed by the University.
 5. The examination shall have the following components:
• Written 300 marks
• Oral & practical/clinical examination 300 marks
• Log Book Evaluation 200 marks (50 marks per year)

6. There shall be two written papers of 150 marks each.

7. Both papers shall have problem-based short/modified essay questions and MCQs.
8. Oral & practical/clinical examination shall have 300 marks for: i. 1 Long Case 100 ii. 4 Short Cases
100 (25 marks each) iii. OSCE 100
9. To be declared successful in Part-II examination the candidate must secure 60% marks in each
component and 50% in each sub-component. Curriculum/Statutes & Regulations-MD Internal
Medicine 13
10. Only those candidates, who pass in theory papers, will be eligible to appear in the Oral &
Practical/ Clinical Examination.
11. The candidates, who have passed written examination but failed in Oral & Practical/ Clinical
Examination, will re-appear only in Oral & Practical / Clinical examination.
12. The maximum number of attempts to re-appear in oral & practical /clinical Examination alone
shall be three, after which the candidate shall have to appear in both written and oral &
practical/clinical examinations as a whole.
13. The candidate with 80% or above marks shall be deemed to have passed with distinction.
14. Log Book/Assignments: Through out the length of the course, the performance of the candidate
shall be recorded on the Log Book.
15. The Supervisor shall certify every year that the Log Book is being maintained and signed
regularly.
16. The Log Book will be developed & approved by the Advanced Studies & Research Board.
17. The evaluation will be maintained by the Supervisor (in consultation with the Co- Supervisor, if
appointed).
18. The performance of the candidate shall be evaluated on annual basis, e.g., 50 marks for each
year in four years MD Internal Medicine course. The total marks for Log Book shall be 200.The
log book shall reflect the performance of the candidate on following parameters:
• Year wise record of the competence of skills
• Year wise record of the assignments
• Year wise record of the evaluation regarding attitude & behavior
• Year wise record of journal club / lectures / presentations / clinico-pathologic conferences
attended & / or made by the candidate.

3. Submission / Evaluation of Synopsis:

i. The candidates shall prepare their synopsis as per guidelines provided by the Advanced Studies
& Research Board, available on LUMHS website. Curriculum/Statutes & Regulations-MD Internal
Medicine.
 ii. The research topic in clinical subject should have 30% component related to basic sciences and
70% component related to applied clinical sciences. The research topic must consist of a
reasonable sample size and sufficient numbers of variables to give training to the candidate to
conduct research, to collect & analyze the data.
iii. Synopsis of research project shall be submitted by the end of the 2nd year of MD program. The
synopsis after review by an Institutional Review Committee shall be submitted to the University
for Consideration by the Advanced Studies & Research Board, through the Principal / Dean
/Head of the institution.

4. Submission of Thesis:

i. Thesis shall be submitted by the candidate duly recommended by the Supervisor.

ii. The minimum duration between approval of synopsis and submission of thesis shall be one year,
but the thesis cannot be submitted later than 7 years of enrolment.
iii. The research thesis must be compiled and bound in accordance with the Thesis Format
Guidelines approved by the University and available on website.
iv. The research thesis will be submitted along with the fee prescribed by the University

5. Award of MD Internal Medicine Degree:

After successful completion of the structured course of MD Internal Medicine and qualifying
Part-I and Part-II examinations in totality, the degree with title MD Internal Medicine shall be
awarded.

Part-II: MD Internal Medicine Part II shall comprise three components:

1. Clinical (both didactic & practical skills and procedures)

2. Research and Thesis writing
3. Log book; Clinical Component Organ and System Competencies in;
i. Gastroenterology and Hepatology:
ii. To provide Residents with opportunities to evaluate and manage patients with a wide
variety of digestive disorders in an inpatient and outpatient setting. The Resident will
act, under the supervision of the attending gastroenterologist, as a consultant to other
clinical services.
iii. To give Residents opportunities to learn about various aspects of a broad range of GI,
liver and pancreatic disorders, with emphasis on the more common disorders.

4. To provide Residents with opportunities to learn the indications, contraindications,

complications, limitations and alternatives for GI procedures.

5. Additional areas include knowledge of nutrition and nutritional deficiencies, and screening
and prevention, particularly for colorectal cancer.
 6. The general internist should have a wide range of competency in gastroenterology and should
be able to provide primary and in some cases secondary preventive care, evaluate a broad array
of gastrointestinal symptoms, and manage many gastrointestinal disorders.

Common Clinical Disorders:

• Malabsorptive/Nutritional disorders
• Inflammatory Bowel Disease
• Irritable Bowel Syndrome
• Peptic Ulcer Diseases
• Malignancies of the Digestive System
• GI disorders and pregnancy
• Gastrointestinal Emergencies
• Indications/complications of GI procedures
• Viral hepatitis
• Chronic liver disease and Cirrhosis
• GI motility disorders
• Biliary disorders
Common Clinical Presentations:
• Abdominal distention
• Abdominal pain
• Abnormal liver function test
• Anorectal discomfort, bleeding, or pruritus
• Anorexia, weight loss
• Ascites
• Constipation
• Diarrhea
• Excess intestinal gas
• Fecal incontinence
• Food intolerance
• Gastrointestinal bleeding
• Heartburn
• Haematemesis
• Indigestion
• Iron-deficiency anemia
• Jaundice
• Liver failure
• Malnutrition
• Melena
• Nausea, vomiting
• Non-cardiac chest pain
• Swallowing dysfunction
Procedure Skills:

• Flexible sigmoidoscopy
• Paracentesis
•Placement of nasogastric tube
• Sengstaken-Blakemore tube (optional) Primary Interpretation of Tests
• Fecal leukocytes
• Test for occult blood Ordering and Understanding tests
• 24-Hour esophageal motility studies and pH monitoring
• Assays for Helicobacter pylori
• Biopsy of the gastrointestinal mucosa
• Blood tests for autoimmune, cholestatic, genetic liver diseases
• Upper endoscopy
• Colonoscopy
• Computed tomography, magnetic resonance imaging, ultrasound of the abdomen
• Contrast studies (including upper gastrointestinal series, small bowel follow through, barium
enema)
• Culture of stool for ova, parasites
• D-Xylose absorption test and other small bowel absorption tests Endoscopic retrograde
Cholangio-pancreatography
• Esophageal manometry
• Examination for stool for ova, parasites
• Fecal electrolytes
• Fecal osmolality
• Interpretation of fecal occult blood tests.
• Gall bladder radionuclide scan
• Gastric acid analysis, serum gastrin level, secretin stimulation test
• Viral hepatitis serology
• Lactose and hydrogen breathe tests
• Laparoscopy
• Laxative screen
• Liver biopsy
• Paracentesis and interpretation of ascitic fluid analysis
• Mesenteric arteriography
• Percutaneous transhepatic cholangiography
• Qualitative and quantitative stool fat
• Scans of gastric emptying
• Serum B12 and Schilling tests
2. PULMONARY MEDICINE
1. The resident must have expertise in understanding the Neoplastic, inflammatory, and infectious
disorders of the lung parenchyma, pleura, and airways; pulmonary vascular disease and its
effect on the cardiovascular system
2. Detection and prevention of occupational and environmental causes of lung disease.
3. Other specialized areas include respiratory failure and sleep-disordered breathing.
4. The general internist should be able to evaluate and manage cough, dyspnea, fever with
infiltrates, mass or nodule on the chest radiograph, pleurisy, and pleural effusion.
5. He or she should also be able to diagnose and manage patients with common respiratory
infections; initiate the diagnostic evaluation of respiratory neoplasm; and manage the initial
approach to patients with respiratory failure, including those in intensive care units.
6. The internist will usually be assisted by the pulmonary specialist for diagnostic procedures and
complicated conditions such as advanced respiratory failure. If such expertise is not available,
the internist, with additional training, may have to assume these roles.

Common Clinical Disorders

• Obstructive lung diseases: COPD, Bronchial Asthma.

• Adult and neonatal respiratory distress syndrome
• Pulmonary vascular disease: Pulmonary HTN, Pulmonary embolism.
• Lower Respiratory Infections: Community-Acquired Pneumonia, Hospital- Acquired
Pneumonia, Chronic pneumonia, and complications of pneumonia
• Diffuse parenchyma lung disease
• Interstitial lung diseases
• Pulmonary disorders of immunosuppressed patients.
• Acute and chronic respiratory failure
• Staging and treatment of lung cancer
• Diagnosis and management of pleural diseases
• Sleep-disordered breathing
• Diagnosis and management of hemoptysis
• Pulmonary Database: History and Physical Examination, Imaging, Pulse Oximetry and
Pulmonary Function Testing
• Pulmonary Rehabilitation/home oxygen therapy, etc
• Pulmonary Procedures: Bronchoscopy, Thoracentesis, Pleural Biopsy, Transthoracic Needle
Biopsy of Lung
Common Clinical Presentations:

1. Chest pain
2. Cough
3. Dyspnea
4. Excessive daytime sleepiness
5. Febrile patient with infiltrate
6. Hemoptysis
7. Nodule or mass on chest radiograph
8. Pleural effusion, pleurisy
9. Strider, hoarseness
10. Wheezing

Procedure Skills

1. Arterial blood gas sampling

2. Endotracheal intubation
3. Monitoring of oxygen saturation
4. Skin test for anergy, tuberculosis
5. Spirometry and peak flow assessment
6. Pulmonary artery catheterization
7. Thoracentesis 8. Pleural biopsy

Primary Interpretation of Tests:

1. Complete pulmonary function tests (Spirometry; measurement of lung volumes, diffusing

capacity, flow volume loop)
2. Pulmonary artery catheter readings
3. Ordering and Understanding Tests
4. Bronchoscopy, including lavage and biopsy
5. Cardiopulmonary exercise test
6. Computed tomography of thorax
7. Cytology, pathology of lung and pleural biopsy specimens
8. Diagnostic studies for venous thrombosis
9. Mediastinoscopy, mediastinotomy
10. Pleural fluid analysis
11. Pulmonary angiography
12. Sleep study
13. Ventilation/perfusion lung scans
3. HEMATOLOGY
The discipline of hematology relates to the care of patients with disorders of the blood, bone marrow,
and lymphatic systems, including Anemias, hematologic malignancies, and other clonal processes, and
congenital and acquired disorders of homeostasis, coagulation, and thrombosis.

The general internist should be competent in:

1. The detection of abnormal physical, laboratory and radiologic findings relating to the lymph
hematopoietic system
2. The assessment of the need for bone marrow aspirate and biopsy and lymph node biopsy
3. The initial diagnostic evaluation and management of the hemostatic and clotting system
4. The assessment of the indications and procedure for transfusion of blood and its separate
components
5. Management of thrombo embolic disorders.
6. The management of therapeutic and prophylactic anticoagulation
7. The diagnosis and management of common Anemias
8. The pharmacology and use of common chemotherapies
9. The management of neutropenia /immunosuppression
10. Principles of management of acute and chronic leukemias
11. Management of gammopathies.

Common Clinical Disorders

Anemias: General aspects and classifications

• Anaemia of pregnancy
• Pancytopenia, aplastic anemia, pure red cell aplasia
• Methemoglobinemia
• Iron overload
• Porphyries
• Haemoglobinopathies
• Hemolytic Anemias
• Qualitative or quantitative disorders of white blood cells
• Disorders of the spleen
• Acquired & inherited coagulation disorders
• Thrombosis and anti thrombotic drugs
• Transfusion of blood and blood components
• Adverse effects of blood transfusion
• Therapeutic aphaeresis
• Classification and differentiation of hematological malignancies
 • Leukemias
• The Myelodysplastic syndromes
• Myeloproliferative disorders
• Lymph proliferative disorders
• Plasma cell dyscrasias
• Bone marrow transplants

Common Clinical Presentations:

• Abnormalities of peripheral smear

• Bleeding, bruising, or petechiae
• Family history of anemia or bleeding disorder
• Lymphadenopathy
• Pallor or fatigue
• Recurrent infections or fever/neutropenia
• Splenomegaly
• Venous or arterial thrombosis, including recurrent thrombosis

Procedure Skills

• Making a peripheral smear

• Therapeutic phlebotomy
• Bone marrow aspiration and core biopsy (optional)
• Primary Interpretation of Tests
• Bone marrow aspiration and core biopsy (optional) Ordering and Understanding Tests
• Evaluating common morphologic abnormalities on all the consults and outpatients as needed.
• Bone marrow aspirate, biopsy, and special stains
• Chromosome analysis-peripheral blood and bone marrow
• Clotting assay, including factor levels and mixing studies
• Hemoglobin electrophoresis
• Iron studies
• Lymph node biopsy and lymphoid cell immunophenotype
• Radiologic, sonographic, and nuclear studies to assess adenopathy, splenomegaly and red cell
mass
• Serum and urine electrophoresis
• Vitamin B12 levels and Schilling rest
 4. INFECTIOUS DISEASES
Infectious disease medicine requires an understanding of the microbiology, prevention, and
management of disorders caused by viral, bacterial, fungal, and parasitic infections, including the
appropriate use of antimicrobial agents, vaccines, and other immunobiologic agents. Important
elements include the environmental, occupational, and host factors that predispose to infection, as well
as basic principles of the epidemiology and transmission of infection.

The general internist should be able to provide appropriate preventive (including optimal use of
immunization and chemoprophylaxis), diagnostic, and therapeutic care for most infections. He or she
should also be able to evaluate symptoms that may be caused by a wide range of infectious disorders. 3.
General internists should also learn about diagnostic and management approaches to patients with HIV
infection.

Common Clinical Disorders

• Principles and practices of infection control and isolation.

• Common infectious diseases including their epidemiology, etiologic pathogens, pathogenesis,
clinical manifestations, differential diagnosis, appropriate application and interpretation of
diagnostic tests, treatment, and prophylaxis for:
• Respiratory tract infections
• Central nervous system infections
• Cardiovascular infections
• Fungal disease
• Mycobacterial infections
• Approach to the Patient with a Parasitic Infection
• Malaria and Babesiosis
• Soft tissue, bone, and joint infections
• Fevers of unknown origin
• Infections in immunocompromised hosts
• Gastrointestinal tract infections
• Genitourinary tract infections including sexually transmitted diseases.
• Infections of indwelling venous and arterial catheters and prosthetic devices
• Nosocomial infections, in intensive care and general care settings
• Animal and human bite wounds
• Infections in drug users
• HIV infection and its associated complications
• Travel-related infections, diagnosis, treatment, and prevention
• Bioterrorism: identifying infections, and understanding public health aspects.
• Bacillus anthracis (Anthrax)
• Yersinia pestis (Plague)
• Variola Major (Smallpox)
• Francisella tularensis (Tularemia)
• Clostridium botulinum (Botulism)
• Filoviruses (Ebola, Marburg)
• Arenaviruses (Lassa)
• Introduction to emerging infectious diseases
• Active Immunization against infectious diseases
• Recommended immunization of infants, children and adolescents. Recommended immunization
of adults.
• Recommended immunizations for travelers.
• Hypersensitivity tests and desensitization.
• Basic principles of anti-infective therapy, including the use of antibacterial, antiviral, antifungal,
anti-mycobacterial, and anti-parasitic agents with regard to mechanisms of action, spectra of
activity, doses and regimens, drug interactions, mechanisms of resistance, appropriate clinical
applications, and adverse effects/toxicities. Common Clinical Presentations
• Abdominal or pelvic pain
• Cellulitis
• Cervicitis, vaginal discharge
• Diarrhea
• Dysuria
• Facial or ear pain
• Fever, including fever in immunosuppressed patient
• Hepatitis
• Joint effusion
• Limb, sacral ulcers
• Lymphadenopathy
• Meningitis
• Penile discharge
• Prevention, public health concerns (immunization, susceptibility and exposure, prophylaxis
• Productive cough, pulmonary infiltrate
• Rash (cellulitis, erythema, petechiae, purpura, tinea)
• Red eye
• Skin abscess
• Sore throat, painful swallowing
• Vomiting Counseling Skills
• Alternative health practices
• HIV risk assessment
• Post-diagnosis counseling
• Substance abuse
Procedure Skills

• Aspiration of skin and soft tissue infections.

• Incision and drainage of superficial abscesses
• Interpretation of gram stained smears.
• Interpretation of microbiology susceptibility reports.
• Proper collection of culture specimens throat, cervix, vagina, rectum, urethra and blood
• Saline and potassium hydroxide preparation of vaginal fluid, skin scrapings
• Tuberculin and anergy panel skin testsOrdering and Understanding Tests
• Antibiotic sensitivity testing and serum levels
• Biopsy of tissues
• CD4 lymphocyte countsCerebrospinal fluid cell count, chemistry, VDRL, cryptococcal antigen,
cytology
• Computed tomography, magnetic resonance imaging of the central nervous system
• Polymerase chain reaction ELISA and Western blot for detection of infectious diseases
• Serology for infections (e.g., Lyme disease, syphilis, etc.)
5. NEPHROLOGY
1. The general internist should be competent to evaluate and appropriately refer patients with
glomerular disorders, asymptomatic urine abnormalities, tubulointerstitial diseases, renal
vascular disease, renal failure, nephrolithiasis, tubular defects, and infections and neoplasms of
the kidneys, bladder, and urethra, and should also be able to provide principle treatment for
some of these conditions.
2. He or she should be able to manage fluid, electrolyte, and acid-base disorders
3. Understand the ways in which systemic diseases may affect the kidneys and recognize the
potential nephrotoxicity of various therapeutic and diagnostic agents.
4. The general internist must also be familiar with guidelines for predialysis management of
patients with renal failure and be able to recognize indications for dialysis and for referral to a
nephrologist.

Although all general internists should know the indications for dialysis, in some cases (for example: if a
nephrologist is unavailable), the general internists may be responsible for initiating and maintaining
patients on peritoneal dialysis.

Common Clinical Disorders

• Fluid and electrolyte disorders

• Acid-base disorders
• Acute renal failure.
• Chronic renal failure
• Evaluation of renal function e.g. Urinalysis, urine protein-creatinine ratio, calculation of GFR.
• Obstructive uropathy.
• Renal stones and management of an acute renal colic.
• Urinary tract infection including pyelonephritis
• Tubulointerstitial disease.
• Chronic kidney disease.
• Glomerulonephropathies
• Nephrotic disease in primary renal disorders.
• Nephrotic disease from systemic disorders.
• Hypertension including hypertensive crises
• Diseases demonstrating nephritic and nephrotic components.
• Cystic diseases of the kidney.
• Multisystem diseases with variable kidney involvement.
• Medullary sponge kidney
• Effects of drugs on the kidneys. CurrPrinciples of renal transplantation
 • Urologic disorders e.g. Bladder outlet obstruction, detection of prostate cancer, and
incontinence
• Renal function and disease in pregnancy
• The kidney and aging.
Common Clinical Presentations
• Abnormalities noted on urinalysis (including proteinuria, hematuria, bacteriuria, pyuria and
cylinduria)
• Complaints referable to bladder outlet (urgency, hesitancy)
• Dysuria
• Edema
• Flank or suprapubic pain or tenderness
• Frequency and complaints referable to increased or decreased urine volume
• Hematuria (gross)
• Hypertension
• Incontinence
• Presenting features of uremia
• Renal colic
• Renal mass or bruit

Procedure Skills:

• Calculation of creatinine clearance

• Calculation of fractional excretion of sodium
• Peritoneal cavity aspiration per indwelling dialysis catheter
• Femoral temporary hemodialysis catheter placement
• Peritoneal dialysis catheterization
• Suprapubic bladder catheterization Ordering and Understanding Tests
• 24-Hour urine excretion of calcium, oxalate, citrate, uric acid and protein
• Computed tomography, magnetic resonance imaging and angiography and ultrasound of the
kidneys
• Creatinine clearance
• Cystometrography
• Cystoscopy
• Fractional excretion of sodium
• Intravenous pyelography
• Radionuclide renal scan
• Renal angiography and venography
• Renal biopsy
• Retrograde pyelography
• Serologic tests for evaluating Glomerulonephritis
• Urinary calculus analysis
• Urine electrolytes (sodium, potassium, chloride)
• Urine/plasma osmolality
6. CARDIOLOGY
1. The general internist should be able to provide primary and secondary preventive care and
initially manage the full range of cardiovascular disorders.
2. The need for additional competencies in cardiovascular disease will depend on the availability
of a cardiologist in the primary practice setting.
3. In some communities, the general internist may be responsible for management of more
complex cardiovascular disorders that require intensive hemodynamic monitoring (for example,
balloon-tipped pulmonary artery catheters) in the intensive care unit.

Common Clinical Disorders:

• Coronary Artery Diseases

• Chronic stable angina. Unstable angina.
• Care of post-CABG and post-PTCA patients.
• Myocardial infarction (covered mainly in the coronary care unit rotation).
• Care of post myocardial infarction patients.
• Congestive heart failure: o Chronic heart failure. O Systolic heart failure from various etiologies
(ischemic/ non ischemic). O Diastolic heart failure.
• Pulmonary edema.
• Valvular heart disease.
• Infective endocarditis.
• Arrhythmias o atrial fibrillation, atrial flutter and other common supraventricular arrhythmias.
Ventricular arrhythmias, sudden cardiac death and indications for AICD implantation.
Bradyarrhythmias and major indication of temporary and permanent pacing. oBasic
understanding of pacemaker function.
• Indication and value of electrophysiologic testing.
• Adult congenital heart disease.
• Cardiomyopathy and myocarditis.
• Preoperative evaluation: oAssessing cardiac risk in patients undergoing non-cardiac surgeries.
oInterventions to minimize cardiac risk in patients undergoing no cardiac procedures.
• Hypertension: oHypertensive urgencies and emergencies. o Management of chronic
hypertension, especially patients with difficult to control hypertension. oSecondary
hypertension.
• Aortic disease (aortic aneurysm).
• Venous thromboembolic disease / pulmonary embolism, pulmonary vascular disease, and
chronic venous stasis.
• Arterial insufficiency
• Pericardial disease
 • Dyslipidemia Common Clinical Presentations
• Abnormal heart sounds or murmurs
• Chest pain
• Dyspnea
• Effort intolerance, fatigue
• Hypertension
• Intermittent claudication
• Leg swelling
• Peripheral vascular disease
• Risk factor modification
• Shock, cardiovascular collapse
• Syncope, lightheadedness Procedure Skills
• Advanced cardiac life support
• Insertion of balloon-tipped pulmonary artery catheter (optional)
• Insertion of temporary pacemaker (optional) Primary Interpretation of Tests Stress
electrocardiography (optional) Ordering and Understanding Tests
• Ambulatory ECG monitoring
• Echocardiography
• Electrophysiology testing
• Left ventricular catheterization and coronary angiography
• Nuclear scan wall motion study
• Right ventricular catheterization (including flotation catheter)
• Stress electrocardiography and thallium myocardial perfusion scan
• Tilt-table physiology study Psychiatry

Ordering and Understanding Tests:

• Ambulatory ECG monitoring

• Echocardiography
• Electrophysiology testing
• Left ventricular catheterization and coronary angiography
• Nuclear scan wall motion study
• Right ventricular catheterization (including flotation catheter)
• Stress electrocardiography and thallium myocardial perfusion scan
• Tilt-table physiology study Psychiatry
7. PSYCHIATRY
1. Understanding of the prevention and treatment of mental disorders and associated emotional,
behavioral and stress-related problems.
2. Given a patient with a chief complaint residents will:
a. Perform a focused history
b. Request appropriate diagnostic tests
c. Formulate a set of working diagnoses,
d. Formulate appropriate treatment plans including referrals.
3. In general internal medicine practice, management of risk factors for mental disorders and early
diagnosis and intervention for established disease (primary and secondary prevention) are
important elements.
4. The general internist should have a wide range of competency in psychiatric disease, particularly
as it is encountered in outpatient settings and should be able to diagnose symptoms and use
pharmacotherapy, behavioral modification, and counseling to provide primary and secondary
preventive care and initially manage many mental disorders.
5. Patients hospitalized for general medical problems and those in the intensive care unit may have
significant psychiatric co morbidity that contributes to general medical morbidity and length of
stay. In these and all other settings, the general internist must be able to evaluate and manage
psychiatric co morbidity effectively with appropriate specialty consultation.
6. The range of competencies expected of a general internist will depend on the availability of
psychiatrists in the primary practice setting.
7. Refractory cases and patients with mental disorders requiring psychotherapeutic interventions
will generally be referred to a psychiatric hospitalization.

Common Clinical Disorders:

• Psychiatric assessment of common psychiatric disorders.

• Substance use disorders.
• Delirium, dementia and other cognitive disorders
• Geriatric psychiatric disorders
• Psychiatric problems associated with hospitalization and medical and surgical disorders

Common Clinical Presentations:

• Agitation or excitement
• Anxiety
• Confusion
• Delusions or bizarre beliefs
• Depressed or sad mood
• Fatigue
• Hallucinations
• Insomnia
• Memory loss
• Poor hygiene or self-care
• Strange speech or behavior
• Suicide risk
• Suspiciousness or feelings of persecution
• Unexplained changes in personality or performance
• Unexplained physical symptoms suggesting somatization Procedure Skills
• Depression inventory
• Mental status examination, including standardized cognitive examinations when indicated
• Ordering and Understanding Tests
• Electroencephalography
• Neuropsychological evaluation
8. ENDOCRINOLOGY, DIABETES, AND METABOLISM
1. The principal endocrine problems handled by the general internist include goiter, thyroid
nodules, thyroid dysfunction, diabetes mellitus, hyper- and hypocalcemia, adrenal cortex hyper-
and hypo function, endocrine hypertension, gonadal disorders, hyper- and hyponatremia,
certain manifestations of pituitary tumors, disorders of mineral metabolism, and
hyperlipidemias.
2. Recognize Type 1 from Type 2 DM
3. Plan dietary therapy, oral hypoglycemic agents and insulin therapy for all diabetics, especially
Type 2 DM patients
4. Plan and advice recommendations for weight loss
5. Understand the concept of tight control, standards of care and targets of control for both Type 1
and Type 2 DM patients
6. Learn the management of acute decompensation of diabetes, i.e. DKA, hyperosmolar state.
7. Learn how to use a multidisciplinary team approach to diabetes management (including role of
cardiology, nephrology, ophthalmology and Podiatry).
8. Learn to interpret thyroid function tests, thyroid imaging and to initiate and follow patients on
thyroid hormone replacement therapy.
9. Diagnosis, evaluation, differential diagnosis and management of overt and subclinical
hyperthyroidism and hypothyroidism, thyroid storm and low uptake versus high uptake
thyrotoxicosis.
10. Approach to thyroid nodules and thyroid cancer.
11. Evaluate and develop treatment strategies for Pituitary disorders – pituitary tumors and
Hypopitutarism, diagnosis, difference between the various etiologies and replacement hormonal
therapies.
12. Learn to approach adrenal diseases including Cushing’s syndrome and adrenal insufficiency
focus on acute and chronic adrenal insufficiency – diagnosis and management.
13. Evaluation, D/D and management of Hypercalcemia (focus on primary hyperparathyroidism) and
Hypocalcemia, Osteoporosis, Osteopenia, Vitamin D deficiency.
14. Endocrine causes of secondary hypertension- Cost efficient evaluation and management.
15. Learn to recognize and treat Poly endocrine autoimmune syndromes.
16. Evaluate and treat male and female hypogonadism (focus on testosterone replacement
Therapy.
17. HRT in females and related reproductive endocrine disorders.
18. Approach to endocrine incidentalomas – (pituitary, adrenal and thyroid with a focus on adrenal
incidentalomas).
19. The general internist must be able to evaluate and manage common endocrine disorders and
refer appropriately. He or she must also be able to evaluate and identify the endocrinologic
implications of abnormal serum electrolytes, hypertension, fatigue, and other nonspecific
presentations.
20. The general internist plays a key role in managing endocrine emergencies, particularly those
encountered in the intensive care unit, including diabetic ketoacidosis and hyperosmolar non
ketotic stupor, severe hyper- and hypocalcemia and Addisonian crisis.

Common Clinical Disorders:

• Pathophysiology of Type 1 & 2 diabetes

• Diagnostic criteria for Diabetes, Differentiate Type I vs. Type II
• Standards of care for a patient with Diabetes `
• Targets of care for a patient with Diabetes
• Metabolic syndromes
• Importance & treatment of Metabolic syndrome
• Life style modifications in metabolic syndrome and diabetes
• Classes of oral anti hypoglycemic agents used and their mechanism of action. indications and
contraindications for each class and side effects Insulin management in Type 1 and 2 DM
• Types of insulin available today (Rapid, Short, Intermediate, Basal, Premixed insulin
preparations)
• Indications, contraindications, complications associated with insulin use
• Insulin protocols used in ICU setting including IV insulin therapy
• Acute diabetes complications, diagnosis and management
• Hyperlipidemia
• Combination therapy to treat diabetic dyslipidemia
• Thyroid function tests in diagnosing various thyroid dysfunction states.
• Interpretation of TSH, FT4, T3, T7, FTI, T3RU, Thyroglobulin
• Role of thyroid scan and radioactive iodine uptake – indications and contraindications for use
• Thyroid imaging – when to use it (ultrasound, CT scan, MRI. Role of PET scan)
• Hyperthyroidism; etiology, pathophysiology, clinical features, diagnosis and management
• Differentiate hyperthyroidism from thyrotoxicosis
• Differential diagnosis of hyperthyroidism (graves’ disease vs toxic MNG, single hot nodule,
thyroiditis etc)
• Thyroid hormone therapy
• Hypothyroidism: primary vs secondary hypothyroidism
• Diagnosis and management
• Thyrotoxic storm and myxedema coma
• Euthyroid sick syndrome
• Approach to thyroid nodules and thyroid cancer
• Endocrine hypertension
• Management – indications for surgery vs medical management
• Phaeochromocytoma:
• Approach to adrenal diseases
• Adrenal insufficiency
• Cushing’s disease
• Hypocalcaemia and hypercalcaemia
• Osteoporosis, osteopenia, vitamin D deficiency
• Incidentalomas:
• Hypopituitarism including pituitary tumors:
• Prolactinomas and Acromegaly
• Hirsutism
• Male and Female Hypogonadism
• Testosterone replacement therapy in males
• Update on the HRT in females
• Polyendocrine autoimmune syndromes Common Clinical Presentations
• Asthenia
• Blood lipid disorders
• Breast discharge
• Change in menstrual, gonadal/sexual function
• Diarrhea
• Disorders of pigmentation
• Goiter (diffuse, nodular)
• Hirsutism
• Hypertension refractory to primary therapy
• Hypotension
• Incidentally discovered abnormalities in serum electrolytes, calcium, phosphate, or glucose
• Mental status changes
• Osteopenia
• Polyuria, polydipsia
• Signs and symptoms of osteopenia
• Symptoms of hyper- and hypoglycemia
• Symptoms of hypermetabolism
• Symptoms of hypometabolism
• Urinary tract stone
• Weight gain, obesity Procedure Skills
• Dexamethasone suppression test (overnight)
• Home blood glucose monitoring
• ACTH stimulation test Ordering and Understanding Tests
• Bone mineral analysis (densitometry)
• Fasting and standardized postprandial serum glucose concentrations
• Glycohemoglobin or serum fructosamine concentration
• Imaging studies of the sella turcica
• Microalbuminuria
• Serum alkaline phosphates activity (for Paget’s disease of bone)
• Serum and urine ketone concentrations (quantitative or qualitative)
• Serum and urine osmolalities
• Serum gonadotropin concentrations (follicle-stimulating hormone, luteinizing hormone)
• Serum lipid profile
• Serum phosphate concentration
• Serum prolactin concentration
• Serum testosterone concentration
• Serum thyroid function tests
• Thyroid scanning and ultrasound
• Urinary calcium, phosphate, uric acid excretion
• Urinary sodium, potassium excretion
• Urine metanephrine, VMA (vanillylmandelic acid), and total catecholamine levels
9. ALLERGY AND IMMUNOLOGY
1. An understanding of immunological basis and management of disorders related to
hypersensitivity or altered reactivity caused by release of immunologic mediators or by
activation of inflammatory mechanisms
2. The general internist should be able to offer primary care for several diseases involving altered
immunity or hypersensitivity.
3. For these diseases, the general internist should be able to initiate diagnostic evaluation and
therapy with or without the help of a sub specialist.
4. The general internist should also be able to recognize many other diseases in which altered
immunity plays an important role.

Common Clinical Presentations:

• Anaphylaxis
• Conjunctival and bulbar inflammation, chemosis, ocular pruritus
• Dyspnea, cough, wheezing, sputum production, use of accessory muscles of respiration
• Nasal obstruction and pruritus, rhinorrhea, sneezing
• Skin wheeling, angioedema, bullous formation, eczematous and papular eruptions, morbilliform
rashes, purpura, pruritus

Procedure Skills:

• Spirometry and spirometric response to bronchodilators

• Wright-Giemsa stain of nasal and pulmonary secretions Primary Interpretation of Tests
• Delayed-hypersensitivity skin tests
• Ordering and Understanding Tests
• Drug desensitization protocols
• Computed tomography of lungs, sinuses
• Immediate skin tests for IgE-mediated reactions to inhalants, food, certain drugs
• In vitro test for specific IgE
• Levels of complement component, C1 esterase inhibitor
• Methacholine inhalation challenge
• Patch tests
• Prick and intradermal skin tests
• Pulmonary function tests (including spirometry, lung volume, diffusion)
• Serum Immunoglobulin levels
• Serum theophylline levels
• T- and B-cell quantitation and subtyping (CD classification)
• Total eosinophil count
10. NEUROLOGY
1. The general internist should possess a broad range of competency in neurology and the
knowledge should encompass the prevention and management of disorders of the central and
peripheral nervous systems.
2. He or she should be able to perform and interpret a detailed neurologic examination, skilled in
localization of the disease process and generation of a differential diagnosis and proper use of
laboratory tests to efficaciously come to a correct diagnosis
3. Knowledge of therapeutics, surgical and medical and primary and secondary prevention of
neurologic diseases and should be familiar with the presenting features, diagnosis, and
treatment of common neurologic disorders and other conditions, such as headache, caused by
non-neural dysfunction
4. The general internist may encounter neurologic disorders in various settings, including
ambulatory care, hospital, long-term care, and home care.
5. In communities where a neurologist is not available, the general internist may be a consultant
for some complex neurologic disorders (for example, control of status epilepticus).

Common Clinical Disorders:

• Headache
• Facial Pain
• Inflammatory meningeal and encephalitic lesions
• Epilepsy
• Syncope and Dysautonomia
• Sensory Disturbances
• Weakness and Paralysis
• Transient Ischemic Attacks
• Stroke
• Intracranial and Spinal Space-Occupying Lesions.
• Nonmetastatic Neurologic Complications of Malignant Disease.
• Pseudotumor Cerebri
• Selected Neurocutaneous Diseases
• Movement Disorders Curriculum/Statutes & Regulations-MD Internal Medicine 49
• Dementia
• Multiple Sclerosis
• Vitamin E Deficiency
• Spasticity
• Myelopathies in AIDS
• Myelopathy of Human T Cell Leukemia Virus
• Subacute Combined Degeneration of the Spinal Cord.
• Wernicke's Encephalopathy
• Stupor and Coma
• Head Injury
• Spinal Trauma
• Syringomyelia
• Motor Neuron Diseases
• Peripheral Neuropathies
• Discogenic Neck Pain
• Brachial and Lumbar Plexus Lesions
• Disorders of Neuromuscular Transmission
• Myopathic Disorders
• Periodic Paralysis Syndrome Common Clinical Presentations
• Abnormal speech
• Abnormal vision
• Altered sensation
• Confusion
• Disturbed gait or coordination
• Dizziness, vertigo
• Headache
• Hearing loss
• Localized pain syndromes: Facial pain, radiculopathy
• Loss of consciousness
• Memory impairment
• Seizure
• Sleep disorder
• Tremor
• Weakness/paresis (generalized, localized) Procedure Skills
• Caloric stimulation test
• Tensilon (edrophonium chloride) test (optional)
• Lumbar Puncture Ordering and Understanding Tests
• Anticonvulsant drug levels
• Carotid Doppler echo scans
• Computed tomography, magnetic resonance imaging of central nervous system
• Digital intravenous angiography
• Electroencephalography, evoked potentials (visual, auditory, sensory)
• Electromyography, nerve conduction studies
• Muscle biopsy
• Myelography
• Screen for toxins, heavy metals
• Sleep study
11. DERMATOLOGY
1. Understanding the morphology, differential diagnosis and management of disorders of the skin,
mucous membranes, and adnexal structures, including inflammatory, infectious, Neoplastic,
metabolic, congenital, and structural disorders.
2. Competence in medical and surgical interventions and dermatopathology are important facets.
3. The general internist should have a general knowledge of the major diseases and tumors of the
skin. He or she should be proficient at examining the skin; describing findings; and recognizing
skin, signs of systemic diseases, normal findings (including benign growths of the skin), and
common skin malignancies.
4. The general internist should be able to diagnose and manage a variety of common skin
conditions and make referrals where appropriate. Common Clinical Disorders
• Primary and secondary lesions of skin
• Inflammatory and infective skin lesions
• Fungal infections
• Pruritus
• Bullous diseases
• Pyoderma/viral infections
• Papulosquamous disease
• Common dermatoses
• Skin cancer
• Skin biopsy technique
• Hair and nail diseaseCommon Clinical Presentations
• Abnormalities of pigmentation
• Eruptions (eczematous, follicular, papulovesicular, vesicular, vesiculobullous)
• Hair loss
• Hirsutism
• Intertrigo
• Leg ulcer
• Mucous membrane ulceration
• Nail infections and deformities
• Pigmented lesion
• Pruritus
• Purpura
• Skin papule or nodule
• Verrucous lesion Procedure Skills
• Application of chemical destructive agents for skin lesions e.g., warts and molluscum,
condyloma
• Incision, drainage, and aspiration of fluctuant lesions for diagnosis or therapy
• Scraping of skin (for potassium hydroxide, mite examination)
• Skin biopsy
• Cryotherapy Primary Interpretation of Tests
• Microscopic examination for scabies, nits, etc.
• Tzanck smear Ordering and Understanding Tests
• Dark-field microscopy
• Fungal culture
• Skin biopsy
12. RHEUMATOLOGY
Rheumatology and Non-operative RHEUMATOLOGY

1. Rheumatology and non-operative orthopedics deal with the prevention, diagnosis, and
management of crystalline diseases, systemic rheumatic diseases, spondyloarthropathies,
vasculitis, inflammatory muscle disease, osteoporosis, osteoarthritis, recreational and sports
injury, and soft-tissue diseases and trauma.
2. The goal of rheumatology is early diagnosis and treatment of these conditions to prevent
disability and death.
3. The general internist needs to have competency in the initial diagnosis and management of
acute arthritis and musculoskeletal disorders and in the long-term care of systemic disorders.
4. He or she must also be proficient in monitoring the effects of anti inflammatory,
immunosuppressive, and cytotoxic drugs.

Common Clinical Disorders

• Purine and uric acid metabolism and crystal-induced arthritis

• Autoimmune disorders (e.g. R.A., S.L.E., Scleroderma and vasculitis)
• Infectious and reactive arthritides
• Metabolic bone diseases e.g. Osteoporosis
• Bone and cartilage disorders e.g. Osteoarthritis
• Nonarticular and regional musculoskeletal disorders
• Inflammatory muscle diseases
• Miscellaneous rheumatic disorders
• Carpal tunnel syndrome (and Tarsal tunnel syndrome)
• Anserine and trochanteric bursitis
• Stenosing tenosynovitis
• Ganglion cysts
• Epicondylitis
• Minor sports-related injuries
• Overuse injuries
• Laboratory and diagnostic tests
• Radiographic imaging and other diagnostic procedures
• Drugs used in rheumatic diseases Common Clinical Presentations
• Joint pain and/or swelling (acute or chronic, monoarticular or polyarticular)
• Muscle aches (localized or diffuse)
• Musculoskeletal weakness
• Nonarticular signs and symptoms of rheumatologic disease, such as Raynaud’s phenomenon and
skin rash
• Regional pain of the neck, shoulder, lower back, hip, knee, hands, or wrists
• Traumatic joint Procedure Skills
• Demonstrate the ability to perform a complete joint examination.
• Therapeutic injection of corticosteroid and arthrocentesis for the knee joint.
• Therapeutic injection of corticosteroid to the periarticular structures (bursal) of the shoulder,
knee, elbow, and foot
• Arthrocentesis of other joints (optional)
• Aspiration of a bursitis
• Aspiration of a ganglion cyst Primary Interpretation of Tests
• Analysis of synovial fluid.
• Plain bone radiographs of joints and spine
• Ordering and Understanding Tests
• Anti-DNA, anti-Sm, anti-RNP, and anti-SS-A antibodies
• Antineutrophil cytoplasmic antibody (ANCA)
• Complement level
• Erythrocyte sedimentation rate
• Fluorescent antinuclear antibody (ANA)
• Rheumatoid factor
• Synovial analysis for crystals
13. ONCOLOGY
1. Medical oncology rotation shall prepare the internist in the diagnosis and management of
benign and malignant lesions of the musculoskeletal system.
2. The general internist should have a wide range of competencies in the evaluation and
management of Neoplastic disease.
3. He or she must be able to identify patients at risk for malignancy and
4. Counsel them regarding risk reduction and screening
5. Investigate clinical syndromes suggestive of underlying malignancy
6. Undertake the palliative care of patients with common solid and hematologic tumors
7. Identify neoplasms with a potential for cure and direct affected patients to the appropriate
centers or providers and participate in the difficult decisions regarding all aspects of
management, including diagnostic evaluation and screening, treatment and palliative care.
8. In addition, the general internist must be familiar with the administration, side effects and drug
interactions of therapeutic agents commonly used for the treatment of malignant disease.
9. Whether a generalist assumes full responsibility for any or all of these functions will depend on
the clinical setting of his or her practice.
10. The general internist should seek subspecialty consultation early in the care of patients with
malignant disease who may be candidates for aggressive treatment with curative intent.

Common Malignant Disorders

• Breast cancer
• Lung cancer - small cell and non-small cell
• Colon cancer
• Prostate cancer
• Ovarian cancer
• Testicular cancer
• Other systemic malignancies common in Pakistan
• Pain management therapy
• Palliative care
• Chemotherapy
• Principles of cancer
• Supportive care
• Screening
• Tumor markers, Oncogenes and apoptosis
• Bone marrow transplantation Common Clinical Presentations
• Anemia
• Ascites
• Bleeding
• Bowel obstruction =
• Cough, hoarseness, hemoptysis
• Lymphadenopathy, soft tissue mass Curriculum/
• Organ enlargement, mass
• Pleural or peritoneal effusion of unknown cause
• Sensory polyneuropathy
• Superior vena cava syndrome
• Weight loss Procedure Skills
• Bone marrow aspiration and biopsy (optional)
• Fine needle aspiration of thyroid and breast (optional)
• Intrathecal chemotherapy (optional) Ordering and Understanding Tests
• Biopsy
• Bone marrow cytogenetics, immunophenotyping
• Cytology and pathology
• Diagnostic and interventional radiology
• DNA content and molecular markers of tumor tissue
• Estrogen and progesterone receptors
• Fiberoptic examinations
• Imaging studies, including computed tomography and magnetic resonance imaging, nuclear
studies
• Serologic markers for tumors
• Ultrasound
14. GERIATRICS/REHABILITATIVE MEDICINE
1. Given an increasingly aging population and the focus on primary care practitioners as the major
care providers, a solid working knowledge and understanding of the principles of geriatric
medicine and long term care is essential for a well-trained general internist.
2. Geriatric aspects of psychiatric diseases
3. Adaptations and maladaptations to systemic diseases, including effects on the body systems
and on laboratory and imaging studies with performance and interpretation of tests.
4. Demonstrate ability to perform assessment of needs and determine most appropriate level of
care for each individual.
5. Demonstrate understanding of basic principles of: interdisciplinary teamwork; skin care and
pressure ulcer prevention; health maintenance and preventive medicine; nutrition; ethics;
clinical pharmacology; discharge planning and appropriate utilization of resources.
6. Understand principles of diagnosis and management of common infections in long term care;
incontinence; delirium, dementia, cognitive impairment; behavior problems; disorders of vision,
hearing, communication; falls; pressure ulcers.
7. Develop ability to assess ADL function and rehabilitation potential.
8. Understand indications for and risks of chemical and mechanical restraints and recognize need
for use of least restrictive means of management.
9. Understand indications for and risks of psychotropic medication in this population and
demonstrate ability to assess for unwanted effects.
10. Demonstrate basic understanding of the most common problems, by organ system, experienced
by the elderly and disabled.

Procedure Skills

• ADL and IADL Assessment

• Mini-Mental Status Exam (MMSE)
• Life Expectancy Estimate
• Geriatric Depression Scale (GDS)
• Decision-Making Capacity Assessment
• Mobility Status Assessment
• Righting Reflex Assessment
• Nutritional Status Assessment
• Medication Review with Recommendations
• Pressure Ulcer Risk Assessment/Prevention
• Pressure Ulcer Staging/Treatment
• Urinary Incontinence Assessment/Management
15. EMERGENCY MEDICINE AND CRITICAL CARE
1. Training in emergency medicine and critical care is crucial for the general internist.
2. A recognition/prioritization medical emergency is the basic knowledge that should be acquired
by the internist.

Important aspects of this training include: identifying patients who are candidates for intensive care,
the bedside approach to the critically-ill patient, knowledge of algorithms for diagnosis and
management of common problems in the ICU, death and resuscitation issues, interaction with
families.

Skills and Procedures:

• Asthma management
• Evaluation of chest pain
• Evaluation of shortness of breath
• Airway management/tracheostomy Barotrauma
• Mechanical ventilation: indications, initial set-up, trouble shooting, weaning
• Critical care nutrition: indications, disease-specific nutrition, writing TPN orders
• Management of Ob/Gynae emergencies
• Oxygen transport: physiology, alterations in the critically-ill
• Arterial blood gases: approach to analysis, common alterations
• Hemodynamics: physiology, PA catheter, hemodynamic waveforms, trouble-shooting
• Critical care pharmacology: pressors / inotropes, antibiotic dosing, drug dosing in ARF
• Shock: pathophysiology, approach to resuscitation
• Fluid and electrolyte disturbances: sodium, potassium, magnesium, calcium
• Acute renal failure: approach differential diagnosis, management
• Coma: pathophysiology, neurological exam, differential diagnosis
• Wound care
• Splinting techniques
• Ophthalmologic emergency management
• Multiple organ dysfunction syndrome
• Acute CHF
• Ethical issues in the ICU
• Management of environmental emergencies
• Basic toxicology principles
• Sepsis prevention in the ICU
• Arterial line insertion
• Central venous catheterization
• Pulmonary artery catheterization
• Assistance in Endotracheal intubation
• Cardiopulmonary resuscitation
• Ordering and rapid interpretation of laboratory tests
3. Thesis Component RESEARCH/ THESIS WRITING Total of one year will be allocated for work on a
research project with thesis writing. Project must be completed and thesis be submitted before
the end of training. Research can be done as one block in 4 th year of training or it can be
stretched over four years of training in the form of regular periodic rotations during the course
as long as total research time is equivalent to one calendar year. Research Experience The active
research component program must ensure meaningful, supervised research experience with
appropriate protected time for each resident while maintaining the essential clinical experience.
Recent productivity by the program faculty and by the residents will be required, including
publications in peer-reviewed journals. Residents must learn the design and interpretation of
research studies, responsible use of informed consent, and research methodology and
interpretation of data. The program must provide instruction in the critical assessment of new
therapies and of the medical literature. Residents should be advised and supervised by qualified
staff members in the conduct of research. Clinical Research Each resident will participate in at
least one clinical research study to become familiar with: 1. Research design 2. Research
involving human subjects including informed consent and operations of the Institutional Review
Board and ethics of human experimentation 3. Data collection and data analysis 4. Research
ethics and honesty 5. Peer review process This usually is done during the consultation and
outpatient clinic rotations. Case Studies or Literature Reviews Each resident will write, and
submit for publication in a peer-reviewed journal, a case study or literature review on a topic of
his/her choice. Laboratory Research Bench Research Curriculum/Statutes & Regulations-MD
Internal Medicine 60 Participation in laboratory research is at the option of the resident and
may be arranged through any faculty member of the Division. When appropriate, the research
may be done at other institutions. Research involving animals Each resident participating in
research involving animals is required to: 1. Become familiar with the pertinent Rules and
Regulations of the University of Health Sciences Lahore i.e. those relating to "Health and
Medical Surveillance Program for Laboratory Animal Care Personnel" and "Care and Use of
Vertebrate Animals as Subjects in Research and Teaching". 2. Read the "Guide for the Care and
Use of Laboratory Animals". 3. View the videotape of the symposium on Humane Animal Care.
Research involving Radioactivity Each resident participating in research involving radioactive
materials is required to: 1. Attend a Radiation Review session 2. Work with an Authorized User
and receive appropriate instruction from him/her.
LOG BOOK
The residents must maintain a log book and get it signed regularly by the supervisor. A
complete and duly certified log book should be a part of the requirement to sit for MD
examination. Log Book should include adequate number of diagnostic and therapeutic
procedures observed and performed indications for the procedure, any complications
and the interpretation of the results, routine and emergency management of patients,
case presentations in CPCs, journal club meetings and literature review.

Proposed Format of Log Book is as follows:

Candidate’s Name: ___________________________________ Roll No. _____________
Supervisor: ___________________________________
The procedures shall be entered in the log book as per format.
Procedures Performed

SR.# DATE NAME OF PATIENT, AGE, DIAGNOSIS PROCEDURE SUPERVISOR’S

SEX & ADMISSION NO. PERFORMED SIGNATURE
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Emergencies Handled

SR.# DATE NAME OF PATIENT, AGE, DIAGNOSIS PROCEDURE SUPERVISOR’S

SEX & ADMISSION NO. MANAGEMENT SIGNATURE
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
Case Presented

SR.# DATE NAME OF PATIENT, AGE, CASE PRESENTED SUPERVISOR’S

SEX & ADMISSION NO. SIGNATURE
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
Seminar/Journal Club Presentation

SR.# DATE TOPIC SUPERVISOR’S SIGNATURE

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
 Evaluation Record
(Excellent, Good, Adequate, Inadequate, Poor)

At the end of the rotation, each faculty member will provide an evaluation of
the clinical performance of the fellow.

SR.# DATE METHOD OF EVALUATION RATING SUPERVISOR’S

(ORAL, PRACTICAL, THEORY) SIGNATURE
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
 Evaluation of MD Teaching Skill Practice
(Theory Class / Clinics / Practicals / Demonstrations / Tutorial
/ Group Discussion)
S. No. Date Topic of Class/ Average Name of the Initials of
Teaching Clinics/ Grade Supervising Guide
Practicals/ Faculty
Demons: