12- Chronic Diarrhea: Amebiasis**, Giardiasis*, Malabsorption syndromes like Celiac Disease* and Tropical Sprue
13- Some areas are more important for medical students to know as compared to others and have been identified by the number of asterisks (No asterisk= nice to know, * = Important, ** and *** =
14- Essential).
15- With Haematochezia Inflammatory bowel diseases: Ulcerative colitis* and Crohn‟s Disease*
16- Irritable bowel syndrome*.
17- Constipation*.
18 Irritable Bowel Syndrome, Diet and sedentary life style, Hypothyroidism, Carcinoma descending colon
19- Ascites**.
20- Chronic Liver Disease**, Malignancy*, Abdominal tuberculosis**.
21- Jaundice**.
22- Congenital hyperbilirubinemia (Gilbert Syndrome and Dubin Johnson Syndrome)
23- Wilson‟s Disease
24- Haemolytic: Malaria, Auto-immune, Hypersplenism
25- Differentiate from Obstructive (Re-enforcement) *: Gall Stones, Carcinoma Pancreas, Cholangitis, Obstructive phase of Hepatitis
26- Hepatitic**: Viral** (acute and chronic), Toxic and Drugs).
27- Haematemesis and / or Melena**.
28- Esophageal varices*, Mallory Weiss Syndrome, Carcinoma Stomach, Cirrhosis of Liver** and Bleeding peptic ulcer**.
29- Bleeding per rectum*.
30- Bacillary dysentery, Inflammatory Bowel Disease, Hemorrhoids*, and Amoebic dysentery**.
31- Abdominal Pain
32- Acid peptic Disease**, Irritable Bowel Syndrome*, Carcinoma stomach, Pancreatitis* and Porphyria
33- Abdominal Mass: Visceromegaly
34- Liver: Hepatitis**, Liver abscess*, Hydatid Cyst, Congested
35- Liver*, and Carcinoma (Primary and Secondary)
36- Spleen: Portal Hypertension, Chronic Malaria, Chronic Myeloid Leukemia, and Myelofibrosis
37- Splenomegaly with fever**: Malaria**, Typhoid**, Infective* endocarditis and Miliary tuberculosis*, Visceral Leishmaniasis,
38- Kidney (see below)
39- Abdominal Aneurysm
40- Altered Mentation: Hepatic Encephalopathy** and other causes of altered mentation.
41- Drugs Contraindicated in Liver Diseases*.
3- KIDNEY AND GENITOURINARY SYSTEM
1- Lumbar pain**.
2- Acute pyelonephritis**, Acute papillary necrosis, Renal Infarction, Perinephric abscess (Surgery) * and Urolithiasis (Surgery).
3- Oliguria/Anuria: Acute Kidney Injury**:
4- Nephritides**, Acute Tubular Necrosis**, Drug-induced* (analgesic), Hypersensitivity nephropathy*, Contrast Induced* and (brief) Haemolytic-uremic syndrome
5- Polyuria / nocturia
6- Diabetes mellitus**, Diabetes insipidus, Hypercalcaemia**,
7- Chronic Kidney Disease: Glomerulopathies**, Nephrotic Syndrome**, Hyperuricemia, Drug-induced and Hemolytic uremic syndrome (brief)
8- Psychogenic*.
9- Dysuria*: With and without frequency of Micturition (Urinary Tract infection) **
10- Hematuria with Dysuria*.
11- Cystic infection of the bladder**, Urethritis and Urolithiasis
12- Painless Hematuria*: Renal Tuberculosis*, Renal Cell Carcinoma* and Bladder carcinoma
13- Urinary incontinence
14- Urge Incontinence (Urinary infection* and Bladder neck problems) and Stress
15- Urinary retention
16- Prostatic Enlargement* and Neurogenic bladder
17- Impotence
18- Diabetes mellitus and Psychogenic
19- Renal glycosuria*. Should know the commonly prescribed (analgesics and antibiotics) drugs contra-indicated and drugs to be used with caution in renal insufficiency**.
4- RESPIRATORY SYSTEM
1- Shortness of Breath
2- Episodic: Bronchial Asthma**
3- Acute: Pneumothorax**, Pulmonary Thrombo-embolism** / Acute Cor Pulmnale, Adult respiratory distress syndrome, Acute respiratory failure* (Type I and II) and Mechanical ventilation
4- Chronic: Chronic obstructive airway diseases**, Pleural Effusion**, Environmental and Occupational lung diseases (in brief: Asbestosis, Silicosis, Bagassosis, Byssinosis and Pneumoconiosis), Hypersensitivity pneumonitis and Interstitial lung disease.
5- Fever with Cough
6- Upper respiratory tract infection**
7- Lower respiratory tract infection: Acute and chronic Bronchitis**
8- Pneumonias**: Community acquired, Nosocomial, Lobar and Bronchopneumonia.
9- Cough with Sputum: Bronchiectasis* Hemoptysis: Carcinoma lung* and Tuberculosis**
10- Respiratory Distress
11- Type-I Respiratory Failure: Pneumonia**, Pulmonary Edema** and Pulmonary Embolism **
12- Type-II Respiratory Failure: Chronic Obstructive Pulmonary Disease (COPD) Should be able to debate and select appropriate drugs and treatment for Tuberculosis, Asthma, COPD, and Pneumonia, based on their indications, drug interactions, contra-indications and complications. Should know the drugs contra-indicated and those to be used with caution in pulmonary disease.
5- CARDIOVASCULAR SYSTEM
1- Fever with Murmur*
2- Rheumatic fever** and Infective endocarditis**
3- Shortness of breath wi th Murmur
4- Mitral, Aortic and Pulmonary valve diseases
5- Palpitations
6- Sinus tachycardia*, Paroxysmal Supraventricular Tachycardia**,
7- Acute atrial Fibrillation and atrial flutter**, and Premature atrial and
8- ventricular contractions**
9- Chest Pain**
10- Angina**, Myocardial infarction**, Constrictive pericarditis, and
11- Pericardial effusion
12- Shortness of breath*
13- Orthopnea and/or Paroxysmal Nocturnal Dyspnea**, Left Ventricular
14- Failure**, Congestive Cardiac Failure**, Corpulmonale and
15- Cardiomyopathies (brief).
16- Congenital heart diseases (brief): atrial septal defect, patent ductus
17- arteriosus and ventricular septal defect
18- Hypertension**
19- Atherosclerosis/Arteriosclerosis** and Lipid Disorders**
20- Secondary Hypertension*: Renal Causes* (Polycystic Kidney, Renal
21- Artery Stenosis, Renal Parenchymal Diseases) and Endocrine
22- Disorders** (Gigantism, Acromegaly, Cushing‟s*, Hyperthyroidism and Pheochromocytoma)
23- Postural Hypotension*.
24-Autonomic neuropathy (Diabetes mellitus) and Drug-induced (Antihypertensives,
25- Loop diuretics* and Nitrates)
26- Claudication: Peripheral vascular disease and Ischemia
27- Shock**: Arrhythmias (ventricular tachycardia, fibrillation) and asystole.
28- Syncope*: Arrhythmias, Vasovagal attack and Heat syncope
6- CENTRAL NERVOUS SYSTEM
1- Headache**.
2- Acute Severe: Sinusitis** and Subarachnoid and Intra-cerebral Hemorrhage**.
3- Periodic: Refractive errors, Migraine* and Tension Headaches*
3- Progressive: Space-occupying lesion
4- With Fever**: Meningitis** (Bacterial, Tuberculosis and Viral), Encephalitis** and Brain abscess.
5- Nuchal headaches/Neck pain: Muscle spasm (Tension, Postural) and Cervical spondylosis*.
6- Facial Pain: Trigeminal neuralgia
7- Squint: Cranial nerves III, IV and VI (Cavernous sinus thrombosis)
8- Intellectual Impairment
9- Impaired Memory and Dementia*
10- Confusional states/Delirium/Encephalopathy**: Substance abuse, Toxins and Poisons
11- Paralysis*.Hemiplegia/hemiparesis/monoplegia/quadriplegia**: Thrombotic,
12- Hemorrhagic and Embolic Paraplegia/paraparesis/quadriplegia*: Spinal cord compression, Secondaries in the spine, Transverse Myelitis*, Tuberculous spine*,Syringomyelia and Syringobulbia Focal Neurological Deficit: Multiple sclerosis, Space occupying lesion and Mononeuritis multiplex
13- Facial Weakness: Bell‟s Palsy**
14- Ptosis: Myasthenia Gravis, Horner‟s Syndrome and III nerve palsy
15- Transient Ischemic Attack**
16- Speech disturbances
17- Hypertonia: Myotonia Dystrophica and Parkinsonism *
18- Hypotonia and muscle wasting: Lower motor neuron disease,*
19- Muscle cramps: Metabolic, Overexertion and Idiopathic
20- Movement Disorders:
21- Hyperkinesia: Tremors* (Hyperthyroidism**, Anxiety*, Druginduced, Parkinsonism, Cerebellar*)
22- Fasciculations: Motor neuron disease and Myokymia,
23- Others: Athetosis, Chorea, Hemiballismus, Ballismus, Myoclonus and Carpopedal Spasm (tetany)*
24- Hypokinesia: Parkinson‟s Disease and Drug induced
25- Gait abnormalities:
26- Ataxic: Cerebellar disorder*
27- Shuffling gait: Parkinsonism*
26- Scissor Gait: Cerebral palsy
29- Lurching gait: Post Cerebro-vascular accidents
30- Waddling gait: Proximal myopathy (Thyroid disease, Cushing‟s disease, Vitamin deficiency, steroids
31- Convulsions/Fits**: Tetanus, Epilepsy*, Space-occupying lesion, Head injury and Cerebro-vascular accidents
32- Coma/ Stupor / drowsiness**: Metabolic**, Trauma, Infection** (Meningitis and Encephalitis), Poisoning, Substance abuse (alcohol), Toxins and Cerebrovascular accidents
33- Dizziness: Malignant Hypertension and Anxiety
34- Vertigo: Benign Positional Vertigo*, Meniere‟s disease, Labyrinthitis, Upper Respiratory Tract Infections and Vertebro-basilar insufficiency
35- Congenital Deafness (ENT)
36- Blindness / Blurring of Vision: Occipital Infarction /Hemorrhage, Head injury / Traumatic, Visual Field Defects (pituitary lesions), Malignant hypertension, Transient mono-ocular blindness (Amaurosis fugax), Multiple sclerosis
37- (associated with more deficits), Snake-bite (neurotoxins) and Druginduced
38- Paraesthesias: Polyneuropathy / Peripheral neuropathies
39- Hypoesthesia: Diabetes mellitus**, Vitamin deficiencies (B6 and B12) *, Mono neuritis multiplex*, and Drug induced (INH) *
40- Hyperesthesia: Diabetic Burning feet syndrome and Restless leg syndrome
41- Muscular Weakness:
42- Acute: Periodic Paralysis and Guillain Barre Syndrome*
43- Chronic: Toxic/ Drug Induced, Hypothyroidism and Hyperthyroidism, Vitamin D deficiency*, Motor-neuron disease
44- Myasthenia Gravis.
7- MUSCULOSKELETAL SYSTEM
1- Joint pain and/or Joint swelling:
2- Monoarthritis* or Polyarthritis*
3- Large Joint involvement: Osteoarthritis, Septic arthritis*,Haemarthrosis and polyarthritis migricans* (Rheumatic fever)
4- Small joint involvement (Inflammatory): Rheumatoid Arthritis*, Systemic Lupus Erythematosus* and Gout*
5- Easy Fractures: Osteoporosis*
6- Bone Pain:Osteomalacia*, Osteomyelitis, Hyperparathyroidism, Malignancy
7- (Multiple Myeloma, Osteosarcoma, Secondaries in the bone and Leukemias)
8- Neck Pain: Cervical spondylosis* and Tension
9- Dorsal Pain: Tuberculosis*
10- Low back pain: Sciatica (Herniated disc) *, Inflammatory (Ankylosing spondylitis and Sacro-iliitis), Secondaries, Lumbar spondylosis, Mechanical/postural, Vertebral Collapse (Tuberculosis and Osteoporosis)
11- Claudication: Spinal stenosis**
12- Increased skin elasticity and hypermobility of joints: Ehlers Danlossyndrome and Marfan's Syndrome
13- Muscle stiffness and pain: Depression, Anti-psychotic drugs and Fibromyalgia
8- BLOOD
1- Pallor: Anaemias.
2- Microcytic Hypochromic (Iron deficiency)**: Increased Loss and Decreased uptake (Malabsorption, Tuberculous and Hookworms)
3- Macrocytic Megaloblastic** (B-12 deficiency and Folic acid deficiency),
4- Normocytic normochromic*: Anemia of chronic inflammation, Malignancies and Renal failure
5- Hemolytic anemia*: Hereditary (Thalassemia*, Sickle cell anemia, Hereditary spherocytosis), Acquired (Blood Transfusion incompatibility, Autoimmune and Valve replacement)
6- Intra-corpuscular: G6P Deficiency, Malaria, Sickle cell syndromes(brief) and Thalassaemias
6- Extra-corpuscular Intravascular
7- Aplastic anemia: Myelofibrosis and Drug-induced Hepatosplenomegaly (Myeloproliferative diseases).
8- With pallor: Chronic myeloid leukemia and Kala Azar Without pallor: Polycythemia rubra vera, Essential thrombocytosis Pallor with Lymphadenopathy and/or lassitude
9- Leukemias**: Acute and Chronic and
10- Lymphomas**: Non-Hodgkin‟s and Hodgkin‟s. Blood groups and blood transfusion**. Fever with lymphadenopathy: Infectious mononucleosis Bleeding and / purpura
11- Clotting Disorders: Decreased production and increased destruction
12- Von Willebrand‟s disease,
13- Disseminated intravascular coagulation (DIC) **,
14- Hemophilia
15- Vitamin K deficiency
16- Anticoagulant Therapy*: Injectable and oral including anti-platelet agents
17- Bleeding Disorders: Epistaxis (Hypertension), Thrombocytopenia (Immune/ Idiopathic* and Acquired Thrombocytopenic purpura), Vessel wall disorders, Thrombocytic Dysfunction and Drug-induced bleeding (Polypharmacy).
9- METABOLIC AND ENDOCRINAL DISORDERS
1- Generalized Pigmentation
2- Endocrinal: Addison‟s Disease, with Diabetes Mellitus(Haemochromatosis in brief)
3- Drug-induced: Chloroquine, Heavy Metals and Chemotherapy Polyuria and Polydipsia: Diabetes mellitus*** and hyperglycemic states**. Growth Abnormalities:
4- Tall stature: Gigantism and Acromegaly
5- Short Stature: Hypothyroidism**, Obesity: Cushing‟s syndrome andHypothyroidism**
6- Infertility: Hypogonadism, Primary Ovarian failure and SheehansSyndrome
10-INFECTIOUS DISEASES
1- Common infections in the organ-systems listed above,
2- With emphasis on those common in Pakistan: Tuberculosis, Malaria, Typhoid, Dengue, Pneumonias, Meningitides and encephalitides, Infectious mononucleosis and
3- Those of global importance
11- By the end of 5 years, medical graduates should be able to perform
and/or provide:
1- Basic Life Support (MANDATORY).
2- Inject I/V, I/M, S/C, intradermal injections
3- Insert and maintain I/V lines.
4- Administer Blood transfusion (Know the indications, contraindications and complications of blood transfusions).
5- Treatment for Acute Pulmonary Edema and anti-platelet therapy
6- Oxygen therapy
6- Should know the indications, complications, different modes ofOxygen delivery
7- Peak expiratory flowmetry.
8- Nebulisation
9- Educate the patient regarding correct inhaler technique
9- Should be able to take an Electrocardiogram
10- Should be able differentiate normal electrocardiograms from common abnormalities of ischemia, left ventricular hypertrophy and arrhythmias (acute myocardial infarction/ischemia, complete heart block, atrial premature contractions, ventricular premature contractions, supraventricular tachycardia, ventricular tachycardia, left bundle branch block and hyperkalemia)
11- Prepare a slide for examination of Malarial Parasite and its examination.
12- Urinary catheterization and collect urine samples
13- Urinalysis by dipstick or other method.
14- Large bowel enema.
12- Interpret and/or identify:
1- The common radiological findings of bone and joint diseases (Rheumatoid arthritis, Osteoarthritis, Vertebral collapse, Caries spine, Cervical rib, etc.)
2- Should know the indications, contra-indications to order tests appropriately and should be able to interpret reports of
3- Order and interpret results: urinalysis, culture and sensitivity, serum creatinine, blood urea, protein estimation, creatinine clearance, ultrasound etc.
4- Echocardiography, Stress testing, Angiography, and the conclusions of Thallium Scan
5- Pulmonary function tests.
6- Arterial blood gas estimations
7- Thyroid function tests
8- Understand the conclusion of HR CT of the lungs.
9- Should know the indications, contra-indications and complications for
10- Holter monitoring, Nitrate Infusion, and Digitalization.
11- PROCEDURES TO BE OBSERVED/ASSISTED: Preferably on patients but Videos can be an alternative (including the indications, contra indications, steps of the procedure and complications)
12- Passing the N/G Tube, and feeding, suction and stomach wash.
13- Preparing a patient for endoscopy, upper and lower GIT and to observe the procedures.
14- Placing airway and its maintenance.
15- Endotracheal tube placement
16- Endotracheal suction/maintenance of airway/nursing on side etc.
17-Bronchoscopy.
18- Should observe, learn and even may assist electroversion therapy, (AED) with indications, complications etc.
19- Aspiration of fluids (Pleural, Peritoneal, Pericardial and Knee)
20- Under water seal aspiration
21- Lumbar puncture
22- Fine needle aspiration
23- Bone marrow aspiration/Trephine.
24- Peritoneal and Hemodialysis
Kumar and Clark's Clinical Medicine by 
Davidson's Principles and Practice of Medicine by 
Oxford handbook of clinical medicine by 
