Curriculum Forge · Competency Builder

Map each competency across five stages of learning

Lecture → Dyadic → Socratic → Guided Discovery → Research — a spectrum from delivered knowledge to self-directed inquiry. Define what the learner does and what you assess at every stage.

1 · Lecture

2 · Dyadic

3 · Socratic

4 · Guided Discovery

5 · Research

passive reception ────────────────────────→ autonomous inquiry

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MBBS subjects

Reference list — pick a subject as the domain tag when you map a competency to the five stages. Click a chip to show or hide its chapter list below.

Pre-clinical

Anatomy Physiology Biochemistry

Para-clinical

Pathology Microbiology Pharmacology Forensic Medicine & Toxicology Community Medicine (PSM)

Clinical

General Medicine General Surgery Obstetrics & Gynaecology Paediatrics Orthopaedics Ophthalmology Otorhinolaryngology (ENT) Dermatology, Venereology & Leprosy Psychiatry Radiodiagnosis Anaesthesiology Community Medicine (continued)

Residency

Internal Medicine Residency Family Medicine Residency Geriatric Medicine Residency Paediatrics Residency

Reference

Management Management+

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Pre-clinical chapters

Chapter-level breakdown for each pre-clinical subject — use these as the unit of mapping when building competencies above.

Anatomy

Introduction to Anatomy & Anatomical Terminology
- Define anatomical position and use standard directional terms (superior, inferior, medial, lateral, proximal, distal) correctly.
- Describe the anatomical planes of the body (sagittal, coronal, transverse) and their clinical relevance.
- Classify the branches of anatomy (gross, microscopic, developmental, radiological) and their scope.
- Explain basic movement terminology (flexion, extension, abduction, adduction, rotation).
- Identify the major body cavities and their contents.
Upper Limb — Osteology, Muscles, Nerves & Vessels
- Identify the bones of the upper limb and their palpable surface landmarks.
- Describe the brachial plexus formation and trace its major branches.
- Explain the compartments of the arm and forearm and the muscles within each.
- Correlate common nerve injuries (e.g., radial, ulnar, median) with resulting motor and sensory deficits.
- Trace the arterial supply and venous drainage of the upper limb.
Lower Limb — Osteology, Muscles, Nerves & Vessels
- Identify the bones of the lower limb and their key osteological features.
- Describe the formation of the lumbosacral plexus and its major branches.
- Explain the fascial compartments of the thigh and leg and their muscle contents.
- Correlate common nerve and vascular injuries with resulting clinical deficits (e.g., foot drop, claudication).
- Describe the arches of the foot and their functional significance in gait.
Thorax — Chest Wall, Mediastinum, Lungs & Heart
- Describe the bony and muscular components of the thoracic wall and mechanics of respiration.
- Identify the boundaries and contents of the mediastinum.
- Describe the gross anatomy, lobes, and bronchopulmonary segments of the lungs.
- Trace the chambers, valves, and conducting system of the heart.
- Correlate surface landmarks with underlying thoracic viscera for clinical examination.
Abdomen — Wall, Peritoneum & Viscera
- Describe the layers of the anterior abdominal wall and clinically relevant regions/quadrants.
- Explain the peritoneal reflections, mesenteries, and their relation to abdominal viscera.
- Trace the gross anatomy and relations of the stomach, liver, and intestines.
- Describe the blood supply and lymphatic drainage of the gastrointestinal tract.
- Identify common sites of herniation and their anatomical basis.
Pelvis & Perineum
- Describe the bony pelvis, pelvic diaphragm, and differences between male and female pelvis.
- Identify the pelvic viscera and their peritoneal relations.
- Describe the boundaries and contents of the perineum, including the urogenital and anal triangles.
- Trace the blood supply, innervation, and lymphatic drainage of pelvic organs.
- Explain the clinical significance of pelvic diameters in obstetric practice.
Head & Neck
- Identify the bones of the skull and describe the cranial fossae and their contents.
- Trace the course and distribution of the cranial nerves.
- Describe the triangles of the neck and their contents.
- Explain the anatomy of the pharynx, larynx, and thyroid gland.
- Correlate facial and scalp anatomy with common clinical presentations (e.g., facial nerve palsy).
Neuroanatomy — Brain, Spinal Cord & Pathways
- Describe the gross organization of the brain, brainstem, cerebellum, and spinal cord.
- Trace major ascending (sensory) and descending (motor) pathways.
- Describe the blood supply of the brain and the clinical basis of stroke syndromes.
- Explain the ventricular system and cerebrospinal fluid circulation.
- Correlate lesions at various neuroaxis levels with resulting clinical deficits.
Special Senses (Eye & Ear)
- Describe the gross anatomy of the eyeball and its accessory structures.
- Explain the anatomical basis of the visual pathway and pupillary reflexes.
- Describe the external, middle, and inner ear and their functional anatomy.
- Trace the auditory and vestibular pathways.
- Correlate common lesions of the eye and ear with their anatomical basis.
General & Systemic Histology
- Identify the four basic tissue types and their subtypes under the microscope.
- Describe the microscopic structure of major organs across body systems.
- Correlate histological structure with organ function.
- Differentiate normal histology from basic pathological changes.
- Use histological terminology accurately in describing tissue sections.
General Embryology
- Describe the stages of fertilization, cleavage, and implantation.
- Explain gastrulation and the formation of the three germ layers.
- Describe the formation of the neural tube and somites.
- Explain the development and functions of the placenta and fetal membranes.
- Identify critical periods of development and their relevance to teratogenesis.
Systemic Embryology & Congenital Anomalies
- Describe the embryological development of the cardiovascular, respiratory, and gastrointestinal systems.
- Explain the development of the urogenital system and common anomalies.
- Describe limb and craniofacial development and related congenital defects.
- Correlate faulty development with clinically important congenital malformations.
- Explain the embryological basis of common pediatric surgical conditions.
Genetics & Genomic Basis of Disease
- Describe the basic principles of Mendelian and non-Mendelian inheritance.
- Explain chromosomal structure and common numerical/structural abnormalities.
- Interpret a basic pedigree chart for inheritance patterns.
- Describe the genetic basis of common inherited disorders.
- Explain the principles and clinical applications of genetic counseling.
Surface, Radiological & Cross-Sectional Anatomy
- Identify surface landmarks corresponding to underlying organs and structures.
- Interpret normal anatomy on plain radiographs of the chest, abdomen, and limbs.
- Identify key anatomical structures on cross-sectional CT and MRI images.
- Correlate cross-sectional imaging anatomy with clinical examination findings.
- Apply surface anatomy knowledge to common clinical and procedural skills (e.g., venipuncture, lumbar puncture sites).

Physiology

General Physiology & Cell Physiology
- Describe the structure and function of the cell membrane and transport mechanisms across it.
- Explain the resting membrane potential and its ionic basis.
- Describe the mechanisms of cell signaling and receptor physiology.
- Explain homeostasis and feedback control mechanisms in the body.
- Describe the basic principles of body fluid compartments.
Blood & Immunity
- Describe the composition and functions of blood and plasma proteins.
- Explain erythropoiesis, hemoglobin synthesis, and the anemia classification.
- Describe the mechanism of hemostasis and blood coagulation.
- Explain the basis of ABO and Rh blood grouping and transfusion reactions.
- Describe the physiological basis of innate and acquired immunity.
Nerve-Muscle Physiology
- Explain the generation and propagation of the nerve action potential.
- Describe the structure and function of the neuromuscular junction.
- Explain the molecular basis of skeletal muscle contraction.
- Differentiate the physiological properties of skeletal, cardiac, and smooth muscle.
- Describe the classification and physiology of nerve fibers.
Central Nervous System
- Describe the physiological organization of the cerebral cortex and its functional areas.
- Explain the physiology of reflexes and motor control pathways.
- Describe the physiology of sleep and its stages.
- Explain the mechanisms underlying learning and memory.
- Describe the physiological basis of pain sensation and modulation.
Autonomic Nervous System
- Differentiate the anatomical and functional organization of the sympathetic and parasympathetic systems.
- Describe the neurotransmitters and receptors involved in autonomic function.
- Explain the autonomic control of cardiovascular, respiratory, and GI functions.
- Describe the physiological basis of the fight-or-flight response.
- Explain common autonomic dysfunctions and their physiological basis.
Special Senses
- Explain the physiology of phototransduction and visual processing.
- Describe the physiology of sound transduction and auditory pathways.
- Explain the physiological basis of taste and olfaction.
- Describe the physiology of vestibular function and balance.
- Explain the mechanisms of accommodation and pupillary reflexes.
Cardiovascular System
- Describe the cardiac cycle and its correlation with pressure, volume, and ECG changes.
- Explain the origin and conduction of the cardiac impulse.
- Describe the regulation of blood pressure and cardiac output.
- Explain the physiological basis of the ECG and common arrhythmias.
- Describe the regional circulations (coronary, cerebral, and peripheral).
Respiratory System
- Describe the mechanics of breathing and lung compliance.
- Explain gas exchange and the transport of oxygen and carbon dioxide in blood.
- Describe the neural and chemical regulation of respiration.
- Interpret spirometry findings and common lung volumes/capacities.
- Explain the physiological basis of hypoxia and respiratory failure.
Renal Physiology & Body Fluids
- Describe the process of glomerular filtration and its regulation.
- Explain tubular reabsorption and secretion mechanisms along the nephron.
- Describe the renal mechanisms of urine concentration and dilution.
- Explain the role of the kidney in acid-base regulation.
- Describe the regulation of body fluid volume and osmolarity.
Gastrointestinal System
- Describe the physiology of salivary, gastric, and pancreatic secretions.
- Explain the mechanisms of digestion and absorption of nutrients.
- Describe gastrointestinal motility and its neural/hormonal control.
- Explain the physiological functions of the liver and biliary system.
- Describe the gut hormones and their regulatory roles.
Endocrine System
- Describe the mechanisms of hormone synthesis, transport, and action.
- Explain the hypothalamo-pituitary axis and its feedback regulation.
- Describe the physiology of the thyroid, parathyroid, and adrenal glands.
- Explain the physiological regulation of blood glucose by insulin and glucagon.
- Describe the physiological basis of common endocrine disorders.
Reproductive System
- Describe the physiology of spermatogenesis and male reproductive hormones.
- Explain the ovarian and menstrual cycle and their hormonal regulation.
- Describe the physiological changes during pregnancy and parturition.
- Explain the physiology of lactation.
- Describe the hormonal basis of puberty and menopause.
Integrated & Exercise Physiology
- Describe the physiological changes in the cardiovascular and respiratory systems during exercise.
- Explain the concept of homeostasis under stress and adaptive responses.
- Describe the physiology of thermoregulation.
- Explain the physiological basis of acclimatization to high altitude.
- Describe the integrated response of multiple organ systems during physical exertion.

Biochemistry

Biomolecules — Carbohydrates, Lipids & Proteins
- Classify carbohydrates, lipids, and proteins based on their chemical structure.
- Describe the structural organization of proteins (primary to quaternary).
- Explain the classification and biological roles of lipids.
- Describe the structure and function of biological membranes.
- Explain the chemistry of glycoproteins and proteoglycans.
Enzymes & Enzyme Kinetics
- Describe enzyme classification and mechanism of catalysis.
- Explain Michaelis-Menten kinetics and factors affecting enzyme activity.
- Describe the types and mechanisms of enzyme inhibition.
- Explain the regulation of enzyme activity (allosteric, covalent modification).
- Describe the clinical significance of plasma enzymes as diagnostic markers.
Carbohydrate Metabolism
- Describe the steps and regulation of glycolysis.
- Explain the citric acid cycle and its regulatory control points.
- Describe glycogen synthesis and breakdown and their hormonal regulation.
- Explain gluconeogenesis and its role in maintaining blood glucose.
- Describe the biochemical basis of common carbohydrate metabolic disorders.
Lipid Metabolism
- Describe the pathway of fatty acid synthesis and beta-oxidation.
- Explain ketone body formation and its clinical relevance.
- Describe cholesterol synthesis, transport, and regulation.
- Explain lipoprotein metabolism and its role in atherosclerosis.
- Describe the biochemical basis of common lipid disorders.
Protein & Amino Acid Metabolism
- Describe the pathways of amino acid catabolism and transamination.
- Explain the urea cycle and its role in ammonia detoxification.
- Describe the biochemical basis of inborn errors of amino acid metabolism.
- Explain the synthesis and significance of biologically important amino acid derivatives.
- Describe protein turnover and nitrogen balance.
Nucleic Acid Metabolism & Molecular Biology
- Describe the structure and organization of DNA and RNA.
- Explain the processes of DNA replication, transcription, and translation.
- Describe purine and pyrimidine metabolism and related disorders (e.g., gout).
- Explain the principles of gene regulation and mutation.
- Describe common recombinant DNA techniques and their clinical applications.
Vitamins & Minerals
- Classify vitamins as fat-soluble or water-soluble with their sources and functions.
- Describe the biochemical role of vitamins as coenzymes.
- Explain the clinical features of common vitamin deficiency disorders.
- Describe the physiological roles of major and trace minerals.
- Explain the biochemical basis of mineral deficiency and toxicity states.
Nutrition & Energy Metabolism
- Describe the concept of balanced diet and daily energy requirements.
- Explain the biochemical basis of protein-energy malnutrition.
- Describe the concept of basal metabolic rate and its determinants.
- Explain the integration of carbohydrate, lipid, and protein metabolism in the fed and fasting states.
- Describe the biochemical basis of obesity and metabolic syndrome.
Hormones & Endocrine Biochemistry
- Classify hormones based on chemical nature and mechanism of action.
- Describe the biochemical basis of hormone-receptor interactions and signal transduction.
- Explain the biochemistry of second messenger systems.
- Describe the biochemical regulation of blood glucose by hormones.
- Explain the biochemical basis of common endocrine disorders.
Organ Function Tests (Liver, Kidney, Thyroid)
- Interpret common liver function tests and their clinical significance.
- Interpret renal function tests including creatinine clearance and GFR estimation.
- Describe thyroid function tests and their interpretation.
- Explain the biochemical basis of jaundice and its classification.
- Describe the biochemical basis of common organ-specific diagnostic panels.
Acid-Base Balance & Water-Electrolyte Homeostasis
- Describe the buffer systems maintaining blood pH.
- Explain the renal and respiratory compensation mechanisms in acid-base disorders.
- Classify and interpret common acid-base disorders using arterial blood gas values.
- Describe the regulation of water and electrolyte balance.
- Explain the biochemical basis of common electrolyte imbalances.
Immunology
- Describe the structure and function of immunoglobulins.
- Explain the biochemical basis of antigen-antibody interactions.
- Describe the complement system and its activation pathways.
- Explain the biochemical basis of hypersensitivity reactions.
- Describe common immunological laboratory techniques (ELISA, Western blot).
Cancer Biology & Molecular Genetics
- Describe the molecular basis of oncogenes and tumor suppressor genes.
- Explain the biochemical hallmarks of cancer cells.
- Describe the role of tumor markers in diagnosis and monitoring.
- Explain the molecular basis of carcinogenesis.
- Describe the principles of molecular diagnostic techniques used in cancer detection.
Instrumentation & Clinical/Diagnostic Biochemistry
- Describe the principles of spectrophotometry and its clinical applications.
- Explain the principles of chromatography and electrophoresis techniques.
- Describe the principles of centrifugation and its diagnostic uses.
- Explain quality control measures in a clinical biochemistry laboratory.
- Describe the principles of automated analyzers used in diagnostic biochemistry.

Para-clinical chapters

Chapter-level breakdown for each para-clinical subject — use these as the unit of mapping when building competencies above.

Pathology

General Pathology — Cell Injury & Adaptation
- Describe the causes and mechanisms of reversible and irreversible cell injury.
- Explain the morphological patterns of cellular adaptation (atrophy, hypertrophy, hyperplasia, metaplasia).
- Describe the mechanisms and morphology of necrosis and apoptosis.
- Explain the biochemical basis of free radical injury.
- Correlate cell injury mechanisms with common clinical disease processes.
Inflammation & Repair
- Describe the vascular and cellular events of acute inflammation.
- Explain the chemical mediators involved in inflammation.
- Differentiate the morphological patterns of acute and chronic inflammation.
- Describe the process of wound healing and factors affecting it.
- Explain the pathogenesis of granulomatous inflammation.
Hemodynamic Disorders (Thrombosis, Embolism, Shock)
- Describe the pathogenesis of edema and its classification.
- Explain Virchow's triad and the pathogenesis of thrombosis.
- Differentiate types of embolism and their clinical consequences.
- Describe the stages and pathophysiology of shock.
- Explain the mechanisms of infarction and factors influencing its outcome.
Immunopathology
- Classify the types of hypersensitivity reactions with examples.
- Describe the pathogenesis of autoimmune diseases.
- Explain the pathology of transplant rejection.
- Describe the pathological basis of immunodeficiency disorders.
- Correlate immunopathological mechanisms with common systemic diseases.
Neoplasia — General Principles
- Define and classify neoplasms based on behavior and tissue origin.
- Describe the molecular basis of carcinogenesis.
- Differentiate the characteristics of benign and malignant tumors.
- Explain the mechanisms of tumor invasion and metastasis.
- Describe the grading and staging systems used in oncology.
Genetic & Pediatric Disorders
- Describe the pathological basis of chromosomal disorders.
- Explain the mechanisms of single-gene inherited disorders.
- Describe common pediatric tumors and developmental pathologies.
- Explain the pathology of intrauterine growth disorders.
- Correlate genetic mechanisms with common congenital syndromes.
Hematology & Hematopoietic Disorders
- Classify anemias based on morphology and pathogenesis.
- Describe the pathology of leukemias and lymphomas.
- Explain the pathophysiology of bleeding and coagulation disorders.
- Describe the pathology of myeloproliferative disorders.
- Interpret peripheral blood smear and bone marrow findings in common hematologic disorders.
Cardiovascular Pathology
- Describe the pathogenesis of atherosclerosis and its complications.
- Explain the pathology of ischemic heart disease.
- Describe the pathology of hypertensive and valvular heart disease.
- Explain the pathogenesis of cardiomyopathies and myocarditis.
- Describe the pathology of congenital heart diseases.
Respiratory Pathology
- Describe the pathology of obstructive and restrictive lung diseases.
- Explain the pathogenesis of pneumonia and lung abscess.
- Describe the pathology of pulmonary tuberculosis.
- Explain the pathogenesis and classification of lung tumors.
- Describe the pathology of pulmonary vascular disorders.
Gastrointestinal & Hepatobiliary Pathology
- Describe the pathology of gastritis and peptic ulcer disease.
- Explain the pathogenesis of inflammatory bowel disease.
- Describe the pathology of viral and other forms of hepatitis.
- Explain the pathogenesis of cirrhosis and its complications.
- Describe the pathology of common gastrointestinal and hepatobiliary tumors.
Renal & Urinary Tract Pathology
- Describe the pathology of glomerular diseases.
- Explain the pathogenesis of acute and chronic kidney injury.
- Describe the pathology of tubulointerstitial diseases.
- Explain the pathogenesis of urinary tract calculi and obstruction.
- Describe the pathology of renal and bladder tumors.
Male & Female Genital Tract Pathology
- Describe the pathology of common lesions of the cervix, uterus, and ovary.
- Explain the pathogenesis of gestational trophoblastic disease.
- Describe the pathology of prostate and testicular disorders.
- Explain the pathogenesis of common sexually transmitted infections' tissue changes.
- Correlate genital tract pathology with screening and diagnostic methods (e.g., Pap smear).
Breast Pathology
- Describe the pathology of benign breast diseases.
- Explain the classification and pathogenesis of breast carcinoma.
- Describe the role of biomarkers in breast cancer diagnosis and prognosis.
- Explain the pathological basis of breast cancer screening.
- Correlate breast pathology findings with clinical staging.
Endocrine Pathology
- Describe the pathology of thyroid disorders including thyroiditis and neoplasms.
- Explain the pathogenesis of diabetes mellitus and its complications.
- Describe the pathology of pituitary and adrenal disorders.
- Explain the pathogenesis of parathyroid disorders.
- Describe the pathology of neuroendocrine tumors.
Musculoskeletal & Soft Tissue Pathology
- Describe the pathology of metabolic bone diseases.
- Explain the pathogenesis of osteomyelitis and bone tumors.
- Describe the pathology of degenerative and inflammatory joint diseases.
- Explain the classification of soft tissue tumors.
- Correlate musculoskeletal pathology with imaging and biopsy findings.
Nervous System Pathology
- Describe the pathology of common CNS infections.
- Explain the pathogenesis of cerebrovascular disease.
- Describe the pathology of degenerative and demyelinating CNS disorders.
- Explain the classification of CNS tumors.
- Describe the pathology of traumatic brain and spinal cord injury.
Clinical Pathology & Laboratory Methods
- Describe the principles of specimen collection and processing for histopathology and cytology.
- Explain common special stains and their diagnostic applications.
- Describe the principles of immunohistochemistry.
- Explain quality assurance practices in a pathology laboratory.
- Interpret basic cytological and biopsy reports.

Microbiology

General Microbiology & Bacterial Morphology
- Describe the structure and classification of bacteria.
- Explain bacterial growth, nutrition, and reproduction.
- Describe bacterial genetics and mechanisms of gene transfer.
- Explain the principles of Gram staining and other bacteriological stains.
- Describe the normal microbial flora of the human body.
Sterilization, Disinfection & Lab Diagnosis
- Describe the physical and chemical methods of sterilization and disinfection.
- Explain the principles of culture media and bacterial identification.
- Describe the methods of antimicrobial susceptibility testing.
- Explain the principles of specimen collection and transport for microbiological diagnosis.
- Describe biosafety levels and laboratory safety practices.
Immunology & Immunological Techniques
- Describe the components and functions of innate and adaptive immunity.
- Explain the structure and function of antibodies.
- Describe the principles of common serological and immunological tests.
- Explain the mechanism of vaccine-induced immunity.
- Describe the immunological basis of hypersensitivity reactions.
Systematic Bacteriology — Gram-Positive Cocci & Bacilli
- Describe the pathogenesis and laboratory diagnosis of Staphylococcus and Streptococcus infections.
- Explain the virulence factors of common gram-positive bacilli (e.g., Corynebacterium, Bacillus, Clostridium).
- Describe the clinical manifestations of gram-positive bacterial infections.
- Explain the antimicrobial susceptibility patterns of major gram-positive pathogens.
- Describe preventive and control measures for gram-positive bacterial infections.
Systematic Bacteriology — Gram-Negative Organisms
- Describe the pathogenesis of Enterobacteriaceae infections.
- Explain the microbiology and pathogenesis of Vibrio, Salmonella, and Shigella.
- Describe the pathogenesis of Neisseria and Haemophilus infections.
- Explain the laboratory diagnosis of common gram-negative bacterial infections.
- Describe antimicrobial resistance mechanisms in gram-negative organisms.
Mycobacteria & Spirochetes
- Describe the microbiology and pathogenesis of Mycobacterium tuberculosis.
- Explain the laboratory diagnosis of tuberculosis and leprosy.
- Describe the microbiology and pathogenesis of Treponema, Leptospira, and Borrelia.
- Explain the clinical stages and diagnosis of syphilis.
- Describe treatment principles for mycobacterial and spirochetal infections.
General & Systematic Virology
- Describe the structure, classification, and replication of viruses.
- Explain the pathogenesis of common DNA and RNA viral infections.
- Describe the laboratory diagnosis of viral infections.
- Explain the principles of antiviral therapy.
- Describe the epidemiology and prevention of common viral diseases.
HIV & Retroviruses
- Describe the structure and life cycle of HIV.
- Explain the pathogenesis and clinical stages of HIV infection.
- Describe the laboratory diagnosis and monitoring of HIV infection.
- Explain the principles of antiretroviral therapy.
- Describe strategies for prevention and control of HIV transmission.
Medical Mycology
- Classify fungi of medical importance based on morphology.
- Describe the pathogenesis of superficial, subcutaneous, and systemic mycoses.
- Explain the laboratory diagnosis of fungal infections.
- Describe opportunistic fungal infections in immunocompromised patients.
- Explain the principles of antifungal therapy.
Medical Parasitology — Protozoa
- Describe the life cycle and pathogenesis of Plasmodium species.
- Explain the pathogenesis of amoebiasis and giardiasis.
- Describe the laboratory diagnosis of common protozoal infections.
- Explain the pathogenesis of Leishmania and Trypanosoma infections.
- Describe preventive measures for protozoal diseases.
Medical Parasitology — Helminths
- Describe the life cycle and pathogenesis of common intestinal nematodes.
- Explain the pathogenesis of cestode and trematode infections.
- Describe the laboratory diagnosis of helminthic infections.
- Explain the clinical manifestations of filarial infections.
- Describe control and prevention strategies for soil-transmitted helminths.
Medical Entomology
- Classify arthropods of medical importance.
- Describe the role of vectors in disease transmission.
- Explain the life cycle of mosquitoes and their role in disease transmission.
- Describe methods of vector control.
- Explain the epidemiological significance of arthropod-borne diseases.
Hospital Infection Control & Biomedical Waste
- Describe the principles of hospital infection prevention and control.
- Explain the classification and management of biomedical waste.
- Describe standard precautions and personal protective equipment use.
- Explain the surveillance methods for healthcare-associated infections.
- Describe outbreak investigation principles in a hospital setting.
Applied & Diagnostic Microbiology
- Describe the principles of molecular diagnostic techniques (PCR) in microbiology.
- Explain the role of automated culture and identification systems.
- Describe the interpretation of common microbiological reports.
- Explain the principles of antimicrobial stewardship.
- Describe emerging and re-emerging infectious disease threats.

Pharmacology

General Pharmacology — Pharmacokinetics
- Describe the processes of drug absorption, distribution, metabolism, and excretion.
- Explain the concepts of bioavailability and first-pass metabolism.
- Describe the factors affecting drug distribution and plasma protein binding.
- Explain the principles of drug half-life and steady-state concentration.
- Describe routes of drug administration and their pharmacokinetic implications.
General Pharmacology — Pharmacodynamics
- Describe the mechanisms of drug-receptor interactions.
- Explain the concepts of agonists, antagonists, and partial agonists.
- Describe dose-response relationships and therapeutic index.
- Explain mechanisms of drug tolerance and dependence.
- Describe the principles of adverse drug reactions and drug interactions.
Autonomic Nervous System Pharmacology
- Describe the pharmacology of cholinergic agonists and antagonists.
- Explain the pharmacology of adrenergic agonists and antagonists.
- Describe the clinical uses of autonomic drugs.
- Explain the mechanism of neuromuscular blocking agents.
- Describe the toxicology and management of autonomic drug overdose.
Autacoids & Related Drugs
- Describe the pharmacology of histamine and antihistamines.
- Explain the pharmacology of serotonin and its antagonists.
- Describe the pharmacology of prostaglandins and related eicosanoids.
- Explain the clinical applications of autacoid-related drugs.
- Describe the pharmacology of ergot alkaloids.
Cardiovascular Pharmacology
- Describe the pharmacology of antihypertensive drugs.
- Explain the pharmacology of antianginal and antiarrhythmic drugs.
- Describe the pharmacology of drugs used in heart failure.
- Explain the pharmacology of diuretics.
- Describe the pharmacology of lipid-lowering agents.
Drugs Acting on Blood & Hematopoietic System
- Describe the pharmacology of anticoagulants and antiplatelet agents.
- Explain the pharmacology of fibrinolytic drugs.
- Describe the pharmacology of drugs used to treat anemia.
- Explain the pharmacology of hematopoietic growth factors.
- Describe the clinical monitoring required for anticoagulant therapy.
Respiratory System Pharmacology
- Describe the pharmacology of bronchodilators.
- Explain the pharmacology of anti-inflammatory drugs used in asthma and COPD.
- Describe the pharmacology of antitussives and expectorants.
- Explain the pharmacology of drugs used in pulmonary hypertension.
- Describe the clinical use of inhalational drug delivery systems.
Gastrointestinal Pharmacology
- Describe the pharmacology of antacids and anti-secretory drugs.
- Explain the pharmacology of antiemetics and prokinetic agents.
- Describe the pharmacology of laxatives and antidiarrheal drugs.
- Explain the pharmacology of drugs used in inflammatory bowel disease.
- Describe the pharmacology of drugs used to treat H. pylori infection.
Central Nervous System Pharmacology
- Describe the pharmacology of general and local anesthetics.
- Explain the pharmacology of sedative-hypnotics and anxiolytics.
- Describe the pharmacology of antiepileptic drugs.
- Explain the pharmacology of antipsychotics and antidepressants.
- Describe the pharmacology of opioid analgesics and their antagonists.
Autocoids, NSAIDs & Anti-inflammatory Drugs
- Describe the mechanism of action of NSAIDs and their adverse effects.
- Explain the pharmacology of corticosteroids.
- Describe the pharmacology of disease-modifying antirheumatic drugs.
- Explain the pharmacology of drugs used in gout.
- Describe the clinical use of COX-2 selective inhibitors.
Endocrine Pharmacology (Hormones & Antidiabetics)
- Describe the pharmacology of insulin and oral hypoglycemic agents.
- Explain the pharmacology of thyroid and antithyroid drugs.
- Describe the pharmacology of corticosteroids and sex hormones.
- Explain the pharmacology of drugs affecting bone mineral metabolism.
- Describe the pharmacology of pituitary hormone analogs.
Chemotherapy — Antimicrobials
- Describe the classification and mechanism of action of antibacterial drugs.
- Explain the principles of rational antibiotic use.
- Describe the mechanisms of antimicrobial resistance.
- Explain the pharmacology of beta-lactam and other major antibiotic classes.
- Describe the adverse effects and monitoring of common antibiotics.
Chemotherapy — Antivirals, Antifungals & Antiparasitics
- Describe the pharmacology of antiviral drugs including antiretrovirals.
- Explain the pharmacology of antifungal agents.
- Describe the pharmacology of antimalarial and antiprotozoal drugs.
- Explain the pharmacology of anthelmintic drugs.
- Describe drug resistance mechanisms in antiparasitic therapy.
Anticancer Chemotherapy
- Describe the classification and mechanism of action of anticancer drugs.
- Explain the principles of combination chemotherapy.
- Describe the adverse effects of common chemotherapeutic agents.
- Explain the pharmacology of targeted and immunotherapy agents.
- Describe the principles of cell-cycle-specific and non-specific drugs.
Chemotherapy of Tuberculosis & Leprosy
- Describe the first-line and second-line drugs used in tuberculosis treatment.
- Explain the principles of directly observed treatment short-course (DOTS).
- Describe the pharmacology of multidrug therapy for leprosy.
- Explain the management of drug-resistant tuberculosis.
- Describe the adverse effects and monitoring of anti-tubercular drugs.
Immunopharmacology & Vaccines
- Describe the pharmacology of immunosuppressive drugs.
- Explain the mechanism of action of biologic and monoclonal antibody therapies.
- Describe the principles of vaccine development and immunization schedules.
- Explain the pharmacology of drugs used in organ transplantation.
- Describe adverse events following immunization and their management.
Vitamins, Minerals & Miscellaneous Agents
- Describe the therapeutic uses of vitamin and mineral supplements.
- Explain the pharmacology of drugs used in nutritional deficiency states.
- Describe the pharmacology of chelating agents.
- Explain the clinical uses of enzyme preparations and miscellaneous agents.
- Describe drug interactions involving vitamins and minerals.
Principles of Toxicology & Poisoning
- Describe the general principles of management of acute poisoning.
- Explain the pharmacology of common antidotes.
- Describe methods to reduce absorption and enhance elimination of poisons.
- Explain the clinical features and management of common drug overdoses.
- Describe the principles of poison information and prevention.

Forensic Medicine & Toxicology

Introduction to Forensic Medicine & Legal Procedures
- Describe the scope and branches of forensic medicine.
- Explain the legal procedures involved in medicolegal examination.
- Describe the role of a doctor as an expert witness in court.
- Explain the classification of inquests and their procedures.
- Describe types of medicolegal documents and their importance.
Identification (Age, Sex, Stature, Fingerprints)
- Describe the medicolegal methods of age estimation.
- Explain the methods used to determine sex from skeletal remains.
- Describe the methods of stature estimation from bones.
- Explain the principles and significance of fingerprint identification.
- Describe the use of DNA and other modern techniques in personal identification.
Death — Definition, Changes & Postmortem Interval
- Define somatic and cellular death and describe modes of death.
- Describe the early and late postmortem changes.
- Explain the methods used to estimate the time since death.
- Describe the medicolegal significance of postmortem lividity and rigor mortis.
- Explain the factors affecting the rate of decomposition.
Medicolegal Autopsy & Exhumation
- Describe the indications and procedure of a medicolegal autopsy.
- Explain the technique of organ examination during autopsy.
- Describe the procedure and legal requirements for exhumation.
- Explain the precautions to be taken during a medicolegal autopsy.
- Describe the preparation of a postmortem report.
Injuries — Mechanical, Thermal & Firearm
- Classify wounds based on the mechanism of injury.
- Describe the characteristics of injuries caused by blunt and sharp force.
- Explain the medicolegal aspects of thermal injuries (burns and scalds).
- Describe the characteristics of firearm wounds and their medicolegal significance.
- Explain the age estimation of wounds.
Asphyxial Deaths
- Classify the types of asphyxial deaths.
- Describe the postmortem findings in hanging and strangulation.
- Explain the medicolegal differentiation of suicidal, homicidal, and accidental asphyxia.
- Describe the findings in drowning deaths.
- Explain the mechanism and findings in traumatic and smothering asphyxia.
Sexual Offences & Medical Jurisprudence of Sex
- Describe the medicolegal examination in cases of sexual assault.
- Explain the medicolegal aspects of virginity and pregnancy determination.
- Describe the legal definitions and examination protocols for sexual offences.
- Explain the medicolegal aspects of impotence and sterility.
- Describe the collection and preservation of forensic evidence in sexual offence cases.
Forensic Psychiatry
- Describe the legal definitions of unsoundness of mind.
- Explain the medicolegal responsibilities in criminal and civil cases involving mental illness.
- Describe the concept of testamentary capacity.
- Explain the procedure for certification of mental illness.
- Describe the forensic psychiatric aspects of diminished responsibility.
Medical Law, Ethics & Consent
- Describe the principles of medical ethics and professional conduct.
- Explain the legal requirements of informed consent.
- Describe the doctrine of confidentiality and its exceptions.
- Explain the legal aspects of euthanasia and end-of-life care.
- Describe the regulatory bodies governing medical practice.
Consumer Protection & Medical Negligence
- Define medical negligence and describe its essential elements.
- Explain the application of consumer protection law to medical practice.
- Describe the concept of vicarious liability in medical negligence.
- Explain the doctrine of res ipsa loquitur.
- Describe strategies for the prevention of medical negligence claims.
General Toxicology & Principles of Management
- Describe the general principles of diagnosis and management of poisoning.
- Explain the medicolegal aspects of common poisoning cases.
- Describe the methods of collection and preservation of viscera for chemical analysis.
- Explain the general symptoms and signs of poisoning.
- Describe the classification of poisons based on their action.
Corrosive & Irritant Poisons
- Describe the clinical features and management of corrosive acid and alkali poisoning.
- Explain the pathological findings in corrosive poisoning.
- Describe the clinical features of irritant poisons (e.g., arsenic, mercury).
- Explain the medicolegal aspects of irritant poison cases.
- Describe the antidotal treatment for common corrosive and irritant poisons.
Neurotoxic & Deliriant Poisons
- Describe the clinical features and management of opioid poisoning.
- Explain the clinical features of poisoning by CNS depressants and stimulants.
- Describe the clinical features and management of deliriant plant poisoning (e.g., datura).
- Explain the medicolegal aspects of neurotoxic poison cases.
- Describe the antidotal treatment for common neurotoxic poisons.
Insecticides, Pesticides & Agrochemical Poisoning
- Describe the mechanism and clinical features of organophosphorus poisoning.
- Explain the management of organophosphorus and carbamate poisoning.
- Describe the clinical features of aluminium phosphide poisoning.
- Explain the medicolegal significance of agrochemical poisoning in rural settings.
- Describe preventive measures for accidental pesticide poisoning.
Drug Dependence & Deleterious Substances
- Describe the clinical features of common substance use disorders.
- Explain the medicolegal aspects of drug dependence and addiction.
- Describe the effects and management of alcohol intoxication and withdrawal.
- Explain the forensic aspects of common deleterious substances (e.g., solvents).
- Describe the legal framework governing narcotic and psychotropic substances.
Forensic Toxicology & DNA Fingerprinting
- Describe the principles of forensic toxicological analysis.
- Explain the chain of custody requirements for forensic samples.
- Describe the principles and applications of DNA fingerprinting in forensic practice.
- Explain the use of forensic toxicology in medicolegal death investigation.
- Describe emerging techniques in forensic analytical toxicology.

Community Medicine (PSM)

Concept of Health, Disease & Preventive Medicine
- Define health and disease and describe the natural history of disease.
- Explain the levels of prevention in preventive medicine.
- Describe the concept of the iceberg phenomenon in disease.
- Explain the determinants of health.
- Describe the modes of intervention at different levels of prevention.
Epidemiology — Principles & Methods
- Describe the basic principles and uses of epidemiology.
- Explain the measures of disease frequency and association.
- Describe the types and design of epidemiological studies.
- Explain the concept of bias and confounding in epidemiological studies.
- Describe the criteria for establishing causation.
Screening for Disease & Investigation of Epidemics
- Describe the principles and criteria of screening for disease.
- Explain the concepts of sensitivity, specificity, and predictive value.
- Describe the steps involved in the investigation of an epidemic.
- Explain the epidemic curve and its interpretation.
- Describe the principles of outbreak control and containment.
Demography & Family Planning
- Describe the demographic cycle and vital statistics indicators.
- Explain the methods of population data collection (census, registration).
- Describe the various contraceptive methods and their mechanisms.
- Explain the national family planning programme and its components.
- Describe the concept of the demographic transition.
Maternal & Child Health
- Describe the components of antenatal, intranatal, and postnatal care.
- Explain the indicators used to assess maternal and child health status.
- Describe the national programmes related to maternal and child health.
- Explain the concept of high-risk pregnancy and its management.
- Describe strategies for reducing maternal and infant mortality.
Nutrition & Nutritional Disorders
- Describe the classification and assessment of nutritional status.
- Explain the etiology and prevention of protein-energy malnutrition.
- Describe the community-based management of micronutrient deficiency disorders.
- Explain the national nutritional programmes and their objectives.
- Describe methods of nutritional surveillance.
Environmental Health & Sanitation
- Describe the principles of safe water supply and water quality standards.
- Explain the methods of excreta and solid waste disposal.
- Describe the principles of housing and ventilation for health.
- Explain the health hazards associated with air and water pollution.
- Describe the principles of environmental sanitation in disaster situations.
Occupational Health
- Describe the common occupational hazards and their health effects.
- Explain the principles of occupational disease prevention.
- Describe the legislative framework for occupational health and safety.
- Explain the concept of ergonomics in the workplace.
- Describe the role of periodic medical examinations in occupational health.
Communicable Diseases — Respiratory & Contact
- Describe the epidemiology and control of tuberculosis.
- Explain the epidemiology and prevention of respiratory viral infections.
- Describe the epidemiology and control of leprosy.
- Explain the modes of transmission and prevention of contact diseases.
- Describe national programmes for control of respiratory and contact diseases.
Communicable Diseases — Vector-Borne
- Describe the epidemiology and control of malaria.
- Explain the epidemiology and prevention of dengue and other arboviral diseases.
- Describe the epidemiology and control of filariasis.
- Explain integrated vector management strategies.
- Describe national programmes for vector-borne disease control.
Communicable Diseases — Water & Food-Borne
- Describe the epidemiology and prevention of cholera and other diarrheal diseases.
- Explain the epidemiology and prevention of typhoid fever.
- Describe the epidemiology and prevention of viral hepatitis A and E.
- Explain the principles of food safety and hygiene.
- Describe outbreak investigation for water and food-borne diseases.
Non-Communicable Diseases
- Describe the epidemiology and risk factors of cardiovascular disease.
- Explain the epidemiology and prevention of diabetes mellitus.
- Describe the epidemiology and prevention of cancer.
- Explain the national programme for prevention and control of NCDs.
- Describe the concept of the double burden of disease.
Immunization & National Health Programmes
- Describe the national immunization schedule and cold chain system.
- Explain the components of the Universal Immunization Programme.
- Describe major national health programmes and their objectives.
- Explain the concept of herd immunity.
- Describe the surveillance systems for vaccine-preventable diseases.
Health Education & Communication
- Describe the principles and methods of health education.
- Explain the models of health behavior change.
- Describe the use of communication media in health promotion.
- Explain the role of community participation in health education.
- Describe strategies for effective interpersonal communication in healthcare.
Biostatistics
- Describe the methods of data collection, presentation, and summarization.
- Explain measures of central tendency and dispersion.
- Describe the principles of sampling methods.
- Explain the concept and application of tests of significance.
- Describe the principles of correlation and regression analysis.
Health Planning, Management & Health Economics
- Describe the levels of healthcare delivery in the health system.
- Explain the principles of health planning and management cycles.
- Describe the basic concepts of health economics and financing.
- Explain the concept of universal health coverage.
- Describe indicators used to evaluate health programme performance.
Hospital Administration & Disaster Management
- Describe the principles of hospital organization and administration.
- Explain the concept of hospital waste management.
- Describe the principles of disaster preparedness and response.
- Explain the role of public health in disaster and emergency management.
- Describe the components of a hospital's disaster management plan.
International Health & Global Health Organizations
- Describe the role and functions of the World Health Organization.
- Explain the role of international agencies in global health (UNICEF, World Bank).
- Describe the concept and goals of Sustainable Development Goals related to health.
- Explain the principles of international health regulations.
- Describe global initiatives for disease eradication and elimination.

Clinical chapters

Chapter-level breakdown for each clinical subject — use these as the unit of mapping when building competencies above.

General Medicine

Clinical Methods & History Taking
- Elicit a systematic clinical history from a patient.
- Perform a general physical examination correctly.
- Demonstrate correct technique for inspection, palpation, percussion, and auscultation.
- Formulate a provisional and differential diagnosis based on history and examination.
- Document clinical findings in a structured case record.
Clinical vignettes
- A 55-year-old man presents with fatigue. On inspection you note yellowish discoloration of sclera; on palpation the liver edge is felt 3 cm below the costal margin. Point: sequence of clinical method — inspection before palpation guides diagnosis.
- A medical student takes a history but forgets to ask about drug allergies before a ward round prescription is written. Point: history taking must be systematic to avoid preventable errors.
Cardiovascular Diseases
- Diagnose and manage common cases of ischemic heart disease.
- Describe the clinical features and management of heart failure.
- Explain the diagnosis and management of hypertension.
- Describe the clinical presentation and management of valvular heart disease.
- Interpret a 12-lead ECG in common cardiac conditions.
Clinical vignettes
- A 60-year-old diabetic man presents with crushing central chest pain radiating to the left arm, sweating, and ECG shows ST elevation in leads II, III, aVF. Dx: Acute inferior wall myocardial infarction.
- A 68-year-old woman presents with progressive breathlessness, bilateral pedal edema, and raised JVP with bibasal crepitations. Dx: Congestive cardiac failure.
- A 45-year-old hypertensive on irregular medication presents with sudden severe tearing chest pain radiating to the back, with unequal blood pressure in both arms. Dx: Aortic dissection.
Respiratory Diseases
- Diagnose and manage community-acquired pneumonia.
- Describe the diagnosis and management of bronchial asthma and COPD.
- Explain the diagnosis and treatment of pulmonary tuberculosis.
- Interpret chest X-rays and pulmonary function tests.
- Describe the management of respiratory failure.
Clinical vignettes
- A 30-year-old man presents with fever, cough with rusty sputum, and right-sided pleuritic chest pain; chest X-ray shows right lower lobe consolidation. Dx: Community-acquired pneumonia.
- A 25-year-old woman has recurrent episodes of wheeze and breathlessness worse at night, relieved by a bronchodilator. Dx: Bronchial asthma.
- A 40-year-old man with chronic cough, evening rise of temperature, and weight loss has a chest X-ray showing upper lobe cavitary lesion. Dx: Pulmonary tuberculosis.
Gastrointestinal & Hepatobiliary Diseases
- Diagnose and manage peptic ulcer disease and GI bleeding.
- Describe the clinical features and management of viral hepatitis.
- Explain the diagnosis and management of liver cirrhosis and its complications.
- Describe the approach to a patient with jaundice.
- Explain the management of inflammatory bowel disease.
Clinical vignettes
- A 50-year-old chronic alcoholic presents with hematemesis, abdominal distension, and spider naevi on the chest wall. Dx: Variceal bleed due to liver cirrhosis with portal hypertension.
- A 35-year-old man presents with epigastric pain relieved by food, worse at night, with no alarm features. Dx: Duodenal peptic ulcer disease.
- A 20-year-old presents with fever, malaise, and yellowish discoloration of eyes with dark urine after eating street food. Dx: Acute viral hepatitis A.
Renal Diseases
- Diagnose and manage acute kidney injury.
- Describe the clinical features and management of chronic kidney disease.
- Explain the diagnosis and management of nephrotic and nephritic syndrome.
- Describe the indications for renal replacement therapy.
- Interpret renal function tests and urine analysis.
Clinical vignettes
- A 6-year-old child presents with periorbital puffiness, frothy urine, and generalized edema; urine shows heavy proteinuria. Dx: Nephrotic syndrome.
- A 55-year-old diabetic on NSAIDs for chronic pain presents with reduced urine output and rising creatinine over 3 days. Dx: Acute kidney injury.
- A 45-year-old man with long-standing diabetes and hypertension presents with fatigue, pallor, and bilateral shrunken kidneys on ultrasound. Dx: Chronic kidney disease.
Endocrine & Metabolic Diseases
- Diagnose and manage diabetes mellitus and its acute complications.
- Describe the clinical features and management of thyroid disorders.
- Explain the diagnosis and management of adrenal disorders.
- Describe the approach to a patient with electrolyte imbalance.
- Explain the management of metabolic syndrome and obesity.
Clinical vignettes
- A 22-year-old known type 1 diabetic presents with vomiting, abdominal pain, deep sighing breathing, and fruity breath odor. Dx: Diabetic ketoacidosis.
- A 35-year-old woman presents with weight loss, heat intolerance, palpitations, and a diffusely enlarged thyroid with fine tremor. Dx: Graves' disease (hyperthyroidism).
- A 30-year-old woman presents with weight gain, cold intolerance, constipation, and dry skin with delayed relaxation of ankle reflex. Dx: Primary hypothyroidism.
Hematological Diseases
- Diagnose and manage common types of anemia.
- Describe the clinical features and management of leukemias.
- Explain the approach to a patient with bleeding disorders.
- Describe the indications and complications of blood transfusion.
- Interpret a complete blood count and peripheral smear.
Clinical vignettes
- A 20-year-old vegetarian woman presents with fatigue and pallor; peripheral smear shows microcytic hypochromic red cells. Dx: Iron deficiency anemia.
- A 6-year-old boy presents with fever, easy bruising, and gum bleeding; peripheral smear shows numerous blast cells. Dx: Acute leukemia.
- A 40-year-old man presents with recurrent epistaxis and prolonged bleeding after minor trauma since childhood, with normal platelet count but prolonged aPTT. Dx: Hemophilia.
Rheumatology & Connective Tissue Diseases
- Diagnose and manage rheumatoid arthritis.
- Describe the clinical features and management of systemic lupus erythematosus.
- Explain the approach to a patient with joint pain and swelling.
- Describe the diagnosis and management of gout.
- Explain the use of disease-modifying drugs in rheumatologic conditions.
Clinical vignettes
- A 35-year-old woman presents with symmetrical pain and morning stiffness in small joints of both hands lasting over an hour. Dx: Rheumatoid arthritis.
- A 25-year-old woman presents with malar rash, photosensitivity, joint pain, and oral ulcers. Dx: Systemic lupus erythematosus.
- A 50-year-old man presents with sudden severe pain and swelling of the great toe at night after a heavy meat meal. Dx: Acute gouty arthritis.
Neurology
- Diagnose and manage stroke and transient ischemic attacks.
- Describe the clinical features and management of epilepsy.
- Explain the approach to a patient with altered sensorium.
- Describe the diagnosis and management of common headache disorders.
- Perform and interpret a basic neurological examination.
Clinical vignettes
- A 65-year-old hypertensive man develops sudden weakness of the left arm and leg with facial droop while gardening. Dx: Acute ischemic stroke.
- A 19-year-old man has recurrent episodes of sudden loss of consciousness with tonic-clonic movements and tongue bite. Dx: Generalized tonic-clonic seizure/epilepsy.
- A 40-year-old woman presents with recurrent unilateral throbbing headache with nausea and photophobia, relieved by rest in a dark room. Dx: Migraine.
Infectious Diseases
- Diagnose and manage common bacterial and viral infections.
- Describe the clinical features and management of dengue and malaria.
- Explain the approach to a patient with fever of unknown origin.
- Describe the principles of rational antimicrobial use.
- Explain the diagnosis and management of HIV/AIDS-related complications.
Clinical vignettes
- A 25-year-old presents with high-grade fever, retro-orbital pain, myalgia, and a positive tourniquet test with falling platelet count. Dx: Dengue fever.
- A 30-year-old returning from a rural area presents with cyclical fever with chills and rigors every 48 hours, and peripheral smear shows ring forms. Dx: Malaria (P. vivax).
- A 45-year-old man presents with fever for 3 weeks without a clear focus despite basic workup. Dx: Pyrexia of unknown origin — needs systematic evaluation.
Nutritional Disorders
- Assess nutritional status using clinical and anthropometric methods.
- Describe the clinical features of protein-energy malnutrition in adults.
- Explain the diagnosis and management of vitamin deficiency disorders.
- Describe the nutritional management of chronic disease.
- Explain the approach to obesity and metabolic complications.
Clinical vignettes
- A 50-year-old chronic alcoholic presents with confusion, ataxia, and ophthalmoplegia. Dx: Wernicke's encephalopathy (thiamine deficiency).
- A 60-year-old vegan presents with numbness in both feet, glossitis, and macrocytic anemia. Dx: Vitamin B12 deficiency.
- An elderly bedridden patient presents with bleeding gums and perifollicular hemorrhages after months of a fruit-free diet. Dx: Scurvy (Vitamin C deficiency).
Dermatological Manifestations of Systemic Disease
- Recognize skin signs of common systemic and metabolic diseases.
- Describe cutaneous manifestations of connective tissue disorders.
- Explain the skin findings associated with endocrine disorders.
- Describe drug-induced skin reactions and their management.
- Correlate skin findings with underlying systemic pathology.
Clinical vignettes
- A 45-year-old diabetic presents with a well-demarcated, shiny, yellow-brown plaque with telangiectasia over the shin. Dx: Necrobiosis lipoidica diabeticorum.
- A 30-year-old woman with SLE presents with a butterfly-shaped erythematous rash sparing the nasolabial folds. Point: malar rash is a hallmark cutaneous sign of SLE.
- A 50-year-old on long-term steroids for a systemic illness presents with new-onset acne and skin thinning. Dx: Drug-induced (steroid) skin changes.
Psychiatric Aspects in Medicine
- Recognize common psychiatric presentations in medical patients.
- Describe the approach to a patient with anxiety or depression in a medical setting.
- Explain the psychiatric aspects of chronic illness.
- Describe delirium and its differentiation from dementia.
- Explain when to refer a patient for specialist psychiatric care.
Clinical vignettes
- A 70-year-old hospitalized patient with a urinary tract infection develops acute fluctuating confusion and disorientation over 2 days. Dx: Delirium secondary to infection.
- A 55-year-old man newly diagnosed with cancer presents with persistent low mood, poor sleep, and loss of interest for 3 weeks. Point: recognize depression as a comorbid condition needing evaluation in medical illness.
- A 40-year-old with generalized anxiety presents with palpitations and breathlessness after every doctor's visit, with normal cardiac workup. Point: somatic anxiety symptoms can mimic organic disease.
Medical Emergencies & Critical Care
- Manage a patient in cardiac arrest using basic and advanced life support.
- Describe the initial management of shock.
- Explain the approach to a patient with acute respiratory distress.
- Describe the management of common poisoning emergencies.
- Explain the principles of triage in emergency medicine.
Clinical vignettes
- A 60-year-old man suddenly collapses, is unresponsive, and has no palpable pulse. Point: immediate action is to start chest compressions and call for help (BLS/ACLS).
- A 30-year-old trauma patient presents with cold clammy skin, tachycardia, and hypotension after a road traffic accident. Dx: Hypovolemic shock.
- A young woman with severe asthma presents with inability to speak in full sentences, use of accessory muscles, and a silent chest. Dx: Life-threatening acute severe asthma — needs urgent management.
Geriatrics
- Describe the physiological changes of aging relevant to disease presentation.
- Explain the approach to polypharmacy in elderly patients.
- Describe the assessment and management of falls in the elderly.
- Explain the principles of comprehensive geriatric assessment.
- Describe common geriatric syndromes and their management.
Clinical vignettes
- An 80-year-old woman on 9 different medications presents with recurrent falls and dizziness on standing. Point: polypharmacy and orthostatic hypotension are common causes of falls in the elderly.
- A 75-year-old man is brought in after a fall at home with a hip fracture; he lives alone and has poor vision. Point: comprehensive geriatric assessment is needed to identify modifiable fall risk factors.
Clinical Toxicology & Snake Bite
- Describe the clinical features and management of common drug overdoses.
- Explain the classification and management of snake bite.
- Describe the use of antivenom and its complications.
- Explain the general principles of poison management.
- Describe the approach to a patient with an unknown poisoning.
Clinical vignettes
- A farmer is brought with a history of snake bite, ptosis, and difficulty breathing within 2 hours. Dx: Neurotoxic snake envenomation — requires urgent antivenom and airway support.
- A young woman is brought unconscious with pinpoint pupils and slow respiration after ingesting an unknown substance found beside her. Dx: Suspected opioid poisoning.
- A farmer presents with excessive salivation, sweating, miosis, and fasciculations after spraying crops without protective gear. Dx: Organophosphorus poisoning.
Immunology & Allergic Disorders
- Describe the basic mechanisms of hypersensitivity reactions.
- Diagnose and manage anaphylaxis.
- Explain the approach to a patient with suspected drug allergy.
- Describe the clinical features and management of primary immunodeficiency states.
- Explain the principles of immunosuppressive therapy and its complications.
Clinical vignettes
- A 25-year-old develops sudden facial swelling, wheeze, and hypotension minutes after a bee sting. Dx: Anaphylaxis — requires immediate intramuscular adrenaline.
- A 30-year-old develops an itchy rash and fever a week after starting a new antibiotic for a throat infection. Dx: Drug allergy/hypersensitivity reaction.
Environmental & Heat-Related Illness
- Diagnose and manage heat exhaustion and heat stroke.
- Describe the clinical features and management of hypothermia.
- Explain the recognition and management of high-altitude illness.
- Describe the approach to a patient with near-drowning.
- Explain the management of electrical and lightning injuries.
Clinical vignettes
- A laborer working outdoors in peak summer collapses with a core temperature of 41°C, dry hot skin, and confusion. Dx: Heat stroke — a medical emergency requiring rapid cooling.
- A trekker at high altitude develops headache, nausea, and breathlessness a day after rapid ascent. Dx: Acute mountain sickness.
Palliative & End-of-Life Care
- Describe the principles of symptom control in palliative care.
- Explain the assessment and management of cancer pain.
- Describe communication skills for breaking bad news.
- Explain the ethical principles guiding end-of-life care decisions.
- Describe the role of the multidisciplinary team in palliative care.
Clinical vignettes
- A 65-year-old with terminal metastatic cancer has severe uncontrolled pain despite oral tramadol. Point: escalate on the WHO analgesic ladder to a strong opioid such as morphine.
- The family of a terminally ill patient asks the physician to inform the patient there is nothing more wrong, fearing distress from the truth. Point: balancing honest communication and compassionate breaking of bad news.

General Surgery

Surgical Basics — Asepsis, Wound Healing & Sutures
- Describe the principles of surgical asepsis and sterilization.
- Explain the phases and factors affecting wound healing.
- Describe the types of sutures and suturing techniques.
- Explain the classification and management of surgical site infections.
- Describe the principles of wound dressing and drain management.
Clinical vignettes
- A surgeon inadvertently touches an unsterile surface during a hernia repair; two days later the patient develops purulent wound discharge. Dx: Surgical site infection due to breach of asepsis.
- A diabetic patient's abdominal wound edges gape open on the 5th postoperative day while coughing. Dx: Wound dehiscence.
Fluid, Electrolyte & Blood Transfusion in Surgery
- Describe fluid and electrolyte management in the surgical patient.
- Explain the indications and complications of blood transfusion.
- Describe the assessment of fluid deficit and replacement therapy.
- Explain the management of postoperative fluid imbalance.
- Describe the principles of nutritional support in surgical patients.
Clinical vignettes
- A patient develops fever, chills, and back pain 15 minutes after starting a blood transfusion. Dx: Acute hemolytic transfusion reaction — stop transfusion immediately.
- A postoperative patient becomes confused and lethargic with a serum sodium of 118 mEq/L after excessive IV fluid replacement. Dx: Dilutional hyponatremia.
Shock, Hemorrhage & Surgical Critical Care
- Classify and describe the management of hemorrhagic shock.
- Explain the initial resuscitation of a trauma patient.
- Describe the principles of surgical critical care and monitoring.
- Explain the management of sepsis in a surgical patient.
- Describe the indications for surgical intensive care admission.
Clinical vignettes
- A young man after a road accident presents with cold extremities, BP 80/50, pulse 130/min, and pallor. Dx: Hemorrhagic (hypovolemic) shock.
- A postoperative patient develops high fever, hypotension, and tachycardia with a raised white cell count. Dx: Surgical sepsis — needs source control and antibiotics.
Infections, Ulcers, Sinuses & Fistulae
- Describe the classification and management of surgical infections.
- Explain the etiology and management of chronic ulcers.
- Describe the difference between sinus and fistula and their management.
- Explain the approach to a patient with a chronic non-healing wound.
- Describe the management of necrotizing soft tissue infections.
Clinical vignettes
- A diabetic patient presents with a foul-smelling, rapidly spreading, crepitant swelling of the leg with pain out of proportion to exam findings. Dx: Necrotizing fasciitis — surgical emergency.
- A patient has a chronic non-healing ulcer over the medial malleolus with associated varicose veins. Dx: Venous stasis ulcer.
Tumors — General Principles
- Describe the clinical approach to a patient with a suspected tumor.
- Explain the principles of tumor staging and grading.
- Describe the surgical principles of tumor excision.
- Explain the role of biopsy in tumor diagnosis.
- Describe the multidisciplinary approach to cancer management.
Clinical vignettes
- A 55-year-old presents with a hard, fixed, irregular lump; FNAC confirms malignancy. Point: staging investigations are needed before treatment planning.
- A patient with a suspicious breast lump undergoes triple assessment (clinical exam, imaging, biopsy). Point: illustrates standard oncological diagnostic workup.
Skin, Soft Tissue & Breast Diseases
- Describe the diagnosis and management of common skin and soft tissue lesions.
- Explain the clinical evaluation of a breast lump.
- Describe the diagnosis and management of breast cancer.
- Explain the indications for breast conservation versus mastectomy.
- Describe the management of soft tissue sarcomas.
Clinical vignettes
- A 45-year-old woman finds a painless, hard lump in the upper outer quadrant of her breast with skin dimpling. Dx: Carcinoma breast.
- A young woman has a firm, mobile, painless breast lump that varies with her menstrual cycle. Dx: Fibroadenoma.
Head & Neck Surgery
- Describe the surgical approach to thyroid swellings.
- Explain the diagnosis and management of neck lumps.
- Describe the surgical management of salivary gland disorders.
- Explain the approach to a patient with head and neck malignancy.
- Describe complications of thyroid and neck surgery.
Clinical vignettes
- A patient develops hoarseness of voice after thyroidectomy. Dx: Recurrent laryngeal nerve injury.
- A 40-year-old presents with a midline neck swelling that moves upward on protrusion of the tongue. Dx: Thyroglossal cyst.
Esophagus, Stomach & Duodenum
- Describe the diagnosis and management of gastroesophageal reflux disease.
- Explain the surgical management of peptic ulcer complications.
- Describe the diagnosis and management of gastric carcinoma.
- Explain the approach to a patient with dysphagia.
- Describe the management of upper GI bleeding.
Clinical vignettes
- A 60-year-old with long-standing GERD presents with progressive dysphagia, first to solids then liquids, with weight loss. Dx: Carcinoma esophagus.
- A patient with known peptic ulcer disease presents with sudden severe abdominal pain and a rigid, board-like abdomen. Dx: Perforated peptic ulcer.
Liver, Biliary Tract & Pancreas
- Describe the diagnosis and management of gallstone disease.
- Explain the surgical approach to obstructive jaundice.
- Describe the diagnosis and management of acute and chronic pancreatitis.
- Explain the approach to a patient with a liver mass.
- Describe the surgical management of pancreatic tumors.
Clinical vignettes
- A 45-year-old obese woman presents with colicky right upper quadrant pain after fatty meals, radiating to the back. Dx: Acute cholecystitis due to gallstones.
- A 60-year-old presents with painless progressive jaundice and a palpable gallbladder. Dx: Carcinoma head of pancreas (Courvoisier's law).
Small & Large Intestine, Appendix
- Describe the diagnosis and management of acute appendicitis.
- Explain the diagnosis and management of intestinal obstruction.
- Describe the surgical approach to colorectal carcinoma.
- Explain the management of inflammatory bowel disease requiring surgery.
- Describe the approach to a patient with an acute abdomen.
Clinical vignettes
- A 20-year-old presents with periumbilical pain migrating to the right iliac fossa, with fever and rebound tenderness. Dx: Acute appendicitis.
- A 65-year-old presents with colicky abdominal pain, distension, absolute constipation, and vomiting. Dx: Intestinal obstruction.
Anorectal Diseases & Hernias
- Describe the diagnosis and management of hemorrhoids and fistula-in-ano.
- Explain the classification and management of abdominal wall hernias.
- Describe the surgical repair techniques for common hernias.
- Explain the diagnosis and management of anorectal abscess.
- Describe the approach to a patient with rectal bleeding.
Clinical vignettes
- A middle-aged man presents with a painless groin swelling that enlarges on coughing and reduces on lying down. Dx: Inguinal hernia.
- A patient presents with severe pain during defecation and bright red blood on the stool, with a visible tear at the anal margin. Dx: Anal fissure.
Urology
- Describe the diagnosis and management of urinary tract calculi.
- Explain the approach to a patient with urinary retention.
- Describe the diagnosis and management of benign prostatic hyperplasia.
- Explain the surgical approach to urological malignancies.
- Describe the management of urinary tract infections requiring surgical intervention.
Clinical vignettes
- A 60-year-old man presents with poor urinary stream, frequency, and nocturia. Dx: Benign prostatic hyperplasia.
- A 30-year-old presents with sudden severe colicky loin-to-groin pain with hematuria. Dx: Ureteric calculus (renal colic).
Vascular Surgery
- Describe the diagnosis and management of peripheral arterial disease.
- Explain the diagnosis and management of deep vein thrombosis.
- Describe the approach to a patient with varicose veins.
- Explain the management of vascular trauma.
- Describe the indications for vascular surgical intervention.
Clinical vignettes
- A 60-year-old smoker presents with cramping calf pain on walking that resolves with rest. Dx: Intermittent claudication due to peripheral arterial disease.
- A postoperative bedridden patient develops sudden unilateral leg swelling and calf tenderness. Dx: Deep vein thrombosis.
Neurosurgery — Basics
- Describe the initial assessment of a patient with head injury.
- Explain the indications for surgical intervention in traumatic brain injury.
- Describe the clinical features of raised intracranial pressure.
- Explain the approach to a patient with spinal cord compression.
- Describe the basic principles of neurosurgical emergencies.
Clinical vignettes
- A patient after a head injury has a lucid interval followed by deteriorating consciousness and a dilated pupil on one side. Dx: Extradural hematoma.
- An elderly patient on anticoagulants presents with gradual headache and confusion weeks after a minor fall. Dx: Chronic subdural hematoma.
Thoracic & Cardiovascular Surgery Basics
- Describe the management of chest trauma.
- Explain the indications for chest tube insertion.
- Describe the basic surgical approach to lung and mediastinal masses.
- Explain the principles of cardiac surgery for common conditions.
- Describe the postoperative care of thoracic surgical patients.
Clinical vignettes
- A trauma patient has absent breath sounds on one side with hyper-resonance and tracheal deviation away from the affected side. Dx: Tension pneumothorax — needs immediate needle decompression.
- A stab injury patient presents with muffled heart sounds, distended neck veins, and hypotension. Dx: Cardiac tamponade (Beck's triad).
Pediatric Surgery
- Describe the diagnosis and management of common congenital surgical anomalies.
- Explain the surgical approach to pediatric hernias and hydrocele.
- Describe the management of pyloric stenosis.
- Explain the approach to a neonate with intestinal obstruction.
- Describe the principles of perioperative care in pediatric surgical patients.
Clinical vignettes
- A 3-week-old male infant presents with non-bilious projectile vomiting after feeds and a palpable olive-shaped epigastric mass. Dx: Hypertrophic pyloric stenosis.
- A newborn presents with bilious vomiting and abdominal distension within the first day of life. Dx: Intestinal obstruction (e.g., duodenal/jejunal atresia).
Trauma & Burns
- Describe the primary and secondary survey in trauma assessment.
- Explain the classification and initial management of burns.
- Describe the management of polytrauma patients.
- Explain fluid resuscitation formulas in burn management.
- Describe the principles of damage control surgery.
Clinical vignettes
- A patient with 40% total body surface area burns has IV fluid resuscitation calculated using the Parkland formula for the first 24 hours. Point: illustrates burns fluid resuscitation.
- A polytrauma patient is assessed using the ABCDE primary survey approach on arrival in the emergency department. Point: illustrates systematic trauma assessment.
Perioperative Care & Surgical Techniques
- Describe the components of preoperative assessment and optimization.
- Explain the principles of informed consent for surgery.
- Describe common surgical instruments and their uses.
- Explain the principles of minimally invasive surgery.
- Describe the postoperative complications and their management.
Clinical vignettes
- A patient develops fever and reduced breath sounds at the lung base on the first postoperative day. Dx: Atelectasis — most common cause of early postoperative fever.
- A patient develops calf pain and swelling on the 4th postoperative day after major abdominal surgery. Dx: Deep vein thrombosis.
Lymphatic Disorders
- Describe the causes and classification of lymphedema.
- Explain the clinical approach to a patient with lymphadenopathy.
- Describe the diagnosis and management of filarial lymphedema.
- Explain the surgical and conservative management options for lymphedema.
- Describe the complications of chronic lymphatic obstruction.
Clinical vignettes
- A patient from an endemic area presents with massive swelling of one lower limb with thickened skin. Dx: Filarial lymphedema.
- A patient presents with a painless, progressively enlarging cervical lymph node for 3 months with night sweats and weight loss. Dx: Suspected lymphoma — needs lymph node biopsy.
Minimal Access & Laparoscopic Surgery
- Describe the principles and physiology of pneumoperitoneum.
- Explain the indications and contraindications for laparoscopic surgery.
- Describe common laparoscopic instruments and their setup.
- Explain the recognition and management of laparoscopic complications.
- Describe the advantages and limitations of minimal access surgery.
Clinical vignettes
- A patient with symptomatic gallstones undergoes laparoscopic cholecystectomy through 3 small port-site incisions. Point: illustrates advantages of minimal access surgery.
- During laparoscopic surgery, a patient develops sudden hypotension and subcutaneous emphysema. Dx: CO2 gas embolism — complication of pneumoperitoneum.
Basics of Transplantation Surgery
- Describe the principles of organ donation and recipient selection.
- Explain the basic immunology of graft rejection.
- Describe the principles of immunosuppression after transplantation.
- Explain the common complications following organ transplantation.
- Describe the ethical and legal aspects of organ transplantation.
Clinical vignettes
- A recipient develops fever and rising creatinine one week after a kidney transplant, with biopsy showing lymphocytic infiltration. Dx: Acute graft rejection.
- A family is counseled regarding brain-death organ donation for a road traffic accident victim. Point: illustrates the ethical/legal process of deceased-donor transplantation.

Obstetrics & Gynaecology

Anatomy & Physiology of Reproduction
- Describe the anatomy of the female reproductive organs.
- Explain the physiology of the menstrual cycle.
- Describe the physiological changes of pregnancy.
- Explain the hormonal regulation of reproduction.
- Describe the anatomy relevant to obstetric and gynecological procedures.
Clinical vignettes
- A resident identifies the ureter passing beneath the uterine artery during a hysterectomy. Point: illustrates the "water under the bridge" relationship critical to avoiding ureteric injury.
- A woman undergoes a pelvic exam to assess uterine size for dating a pregnancy. Point: illustrates clinical application of pelvic anatomy.
Antenatal Care & Normal Pregnancy
- Perform a complete antenatal examination and risk assessment.
- Describe the schedule and components of routine antenatal care.
- Explain the diagnosis and confirmation of pregnancy.
- Describe the nutritional and health advice given during pregnancy.
- Explain the routine investigations performed during antenatal care.
Clinical vignettes
- A primigravida presents for her first antenatal visit at 12 weeks. Point: illustrates the standard antenatal booking investigation package.
- A 28-year-old at 24 weeks gestation has an abnormal 75g OGTT result. Dx: Gestational diabetes mellitus.
Abnormal Labour & Obstetric Emergencies
- Describe the diagnosis and management of prolonged and obstructed labour.
- Explain the management of malpresentation and malposition.
- Describe the diagnosis and management of umbilical cord prolapse.
- Explain the approach to shoulder dystocia.
- Describe the management of uterine rupture.
Clinical vignettes
- A woman with a previous cesarean section in labour develops sudden severe abdominal pain, cessation of contractions, and fetal distress. Dx: Uterine rupture — obstetric emergency.
- During delivery, the fetal head retracts against the perineum ("turtle sign") after delivery of the head. Dx: Shoulder dystocia.
Normal & Instrumental Delivery
- Describe the mechanism and stages of normal labour.
- Explain the conduct of a normal vaginal delivery.
- Describe the indications and technique of instrumental delivery.
- Explain the management of episiotomy and perineal tears.
- Describe the active management of the third stage of labour.
Clinical vignettes
- A woman has a prolonged second stage of labour; forceps delivery is planned. Point: illustrates indications for instrumental delivery.
- Immediately after delivery, oxytocin is given and controlled cord traction performed. Point: illustrates active management of the third stage to prevent postpartum hemorrhage.
High-Risk Pregnancy & Medical Disorders in Pregnancy
- Identify risk factors for a high-risk pregnancy.
- Describe the management of diabetes and thyroid disease in pregnancy.
- Explain the management of anemia in pregnancy.
- Describe the management of cardiac disease complicating pregnancy.
- Explain the approach to infections in pregnancy (TORCH).
Clinical vignettes
- A pregnant woman with pre-existing type 1 diabetes requires tight glycemic control throughout pregnancy. Point: illustrates management of pre-gestational diabetes.
- A pregnant woman exposed to a febrile rash illness in the first trimester is worked up for congenital infection risk. Dx: Suspected TORCH infection.
Antepartum & Postpartum Hemorrhage
- Describe the causes and management of antepartum hemorrhage.
- Explain the diagnosis and management of placenta previa and abruption.
- Describe the causes and management of postpartum hemorrhage.
- Explain the use of uterotonic agents in hemorrhage management.
- Describe the surgical options for uncontrolled postpartum hemorrhage.
Clinical vignettes
- A woman at 34 weeks presents with painless vaginal bleeding. Dx: Placenta previa.
- A woman soon after delivery has a boggy, poorly contracted uterus with continued heavy bleeding. Dx: Postpartum hemorrhage due to uterine atony.
Hypertensive Disorders of Pregnancy
- Classify hypertensive disorders of pregnancy.
- Describe the diagnosis and management of preeclampsia.
- Explain the management of eclampsia and its complications.
- Describe the use of magnesium sulfate in eclampsia management.
- Explain the timing and mode of delivery in hypertensive disorders.
Clinical vignettes
- A primigravida at 32 weeks presents with BP 160/110, proteinuria, and headache. Dx: Severe preeclampsia.
- A woman with preeclampsia develops a generalized tonic-clonic seizure. Dx: Eclampsia — requires magnesium sulfate.
Puerperium & Postpartum Care
- Describe the physiological changes during the puerperium.
- Explain the routine postpartum care and advice.
- Describe the diagnosis and management of puerperal sepsis.
- Explain the management of postpartum psychiatric disorders.
- Describe postpartum contraceptive counseling.
Clinical vignettes
- A woman on postpartum day 3 develops fever, foul-smelling lochia, and uterine tenderness. Dx: Puerperal sepsis.
- A breastfeeding mother is counseled about the lactational amenorrhea method before starting other contraception. Point: illustrates postpartum contraceptive planning.
Fetal Growth, Surveillance & Disorders
- Describe the methods of fetal growth assessment.
- Explain the diagnosis and management of intrauterine growth restriction.
- Describe the methods of antenatal fetal surveillance.
- Explain the diagnosis and management of multiple pregnancy.
- Describe the approach to fetal congenital anomalies.
Clinical vignettes
- Ultrasound at 36 weeks shows estimated fetal weight below the 10th percentile with reduced amniotic fluid. Dx: Fetal growth restriction.
- A routine 20-week anomaly scan reveals absence of the cranial vault. Dx: Anencephaly.
Infertility & Assisted Reproduction
- Describe the causes of male and female infertility.
- Explain the basic investigations for an infertile couple.
- Describe the principles of ovulation induction.
- Explain the basic concepts of assisted reproductive techniques.
- Describe the counseling required for infertile couples.
Clinical vignettes
- A couple presents after 2 years of unprotected intercourse without conception; the woman has irregular cycles. Point: illustrates systematic infertility workup of both partners.
- A woman with tubal blockage on hysterosalpingography is counseled about in-vitro fertilization. Point: illustrates assisted reproduction options.
Menstrual Disorders & Endocrinology
- Describe the causes and management of abnormal uterine bleeding.
- Explain the diagnosis and management of amenorrhea.
- Describe the diagnosis and management of polycystic ovary syndrome.
- Explain the approach to a patient with dysmenorrhea.
- Describe the hormonal basis of common menstrual disorders.
Clinical vignettes
- A young woman presents with irregular periods, hirsutism, and acne; ultrasound shows multiple small ovarian follicles. Dx: Polycystic ovary syndrome.
- A 45-year-old presents with heavy, prolonged menstrual bleeding without any structural pathology found. Dx: Dysfunctional uterine bleeding.
Genital Tract Infections
- Describe the diagnosis and management of vaginal discharge.
- Explain the diagnosis and management of pelvic inflammatory disease.
- Describe common sexually transmitted infections affecting the genital tract.
- Explain the management of genital tract tuberculosis.
- Describe prevention strategies for genital tract infections.
Clinical vignettes
- A woman presents with foul-smelling vaginal discharge, itching, and dyspareunia. Dx: Vaginitis — requires workup for candidiasis/trichomoniasis.
- A woman presents with fever, lower abdominal pain, and cervical motion tenderness. Dx: Pelvic inflammatory disease.
Benign & Malignant Gynecological Tumors
- Describe the diagnosis and management of uterine fibroids.
- Explain the diagnosis and management of ovarian cysts and tumors.
- Describe the screening and management of cervical cancer.
- Explain the diagnosis and management of endometrial carcinoma.
- Describe the staging and treatment principles of gynecological cancers.
Clinical vignettes
- A postmenopausal woman presents with postmenopausal bleeding; endometrial biopsy shows malignancy. Dx: Endometrial carcinoma.
- A woman in her 50s presents with abdominal distension, early satiety, and a complex adnexal mass with raised CA-125. Dx: Suspected ovarian carcinoma.
Uterovaginal Prolapse & Urogynecology
- Describe the classification and diagnosis of uterovaginal prolapse.
- Explain the conservative and surgical management of prolapse.
- Describe the diagnosis and management of urinary incontinence.
- Explain the approach to a patient with pelvic floor dysfunction.
- Describe the complications of prolapse surgery.
Clinical vignettes
- A multiparous woman complains of a "something coming down" sensation in the vagina, worse on straining. Dx: Uterine prolapse.
- A woman leaks urine on coughing or sneezing but has no associated urgency. Dx: Stress urinary incontinence.
Contraception & Family Planning
- Describe the mechanism and use of various contraceptive methods.
- Explain counseling for contraceptive choice.
- Describe the complications and contraindications of hormonal contraceptives.
- Explain the use of intrauterine devices.
- Describe permanent methods of contraception.
Clinical vignettes
- A woman requests a reversible, long-acting contraceptive method after her second child. Point: illustrates counseling on IUCD or implants.
- A couple who have completed their family opt for a permanent method. Point: illustrates counseling on tubal ligation/vasectomy.
Medical Termination of Pregnancy
- Describe the legal provisions for medical termination of pregnancy.
- Explain the methods of first and second trimester termination.
- Describe the complications of termination of pregnancy.
- Explain the counseling required before and after termination.
- Describe post-abortion care and contraceptive counseling.
Clinical vignettes
- A woman at 8 weeks gestation requests termination of an unwanted pregnancy within the legal gestational limit. Point: illustrates MTP Act eligibility and counseling.
- A woman presents with incomplete abortion and heavy bleeding after taking abortion pills without medical supervision. Point: illustrates complications of unsafe abortion.
Operative Obstetrics & Gynecological Surgery
- Describe the indications and technique of cesarean section.
- Explain the complications of cesarean delivery.
- Describe the indications and technique of hysterectomy.
- Explain the principles of laparoscopic gynecological surgery.
- Describe the perioperative care in gynecological surgery.
Clinical vignettes
- A woman with fetal distress in labour requires an emergency cesarean section. Point: illustrates indications for operative delivery.
- A woman with symptomatic large fibroids not desiring future fertility undergoes hysterectomy. Point: illustrates surgical management of fibroids.
Multiple Pregnancy
- Describe the diagnosis and classification of multiple pregnancy.
- Explain the antenatal management of twin pregnancy.
- Describe the complications specific to multiple pregnancy.
- Explain the management of labour and delivery in multiple pregnancy.
- Describe the fetal complications associated with multiple pregnancy.
Clinical vignettes
- Ultrasound at 12 weeks shows a twin pregnancy with a single placenta and a thin dividing membrane. Dx: Monochorionic diamniotic twins — at risk of twin-to-twin transfusion syndrome.
- A twin pregnancy presents in preterm labour at 32 weeks. Point: illustrates the increased risk of preterm birth in multiple pregnancy.
Preterm Labour
- Describe the risk factors and diagnosis of preterm labour.
- Explain the principles of tocolytic therapy.
- Describe the use of antenatal corticosteroids for fetal lung maturity.
- Explain the management of preterm premature rupture of membranes.
- Describe strategies for the prevention of preterm birth.
Clinical vignettes
- A woman at 30 weeks presents with regular uterine contractions and cervical dilatation. Dx: Preterm labour — requires tocolysis and steroids for fetal lung maturity.
- A woman with a history of previous preterm birth is started on prophylactic progesterone in the current pregnancy. Point: illustrates a preterm birth prevention strategy.
Malposition & Malpresentation
- Describe the diagnosis of malposition and malpresentation in labour.
- Explain the management of occipitoposterior position.
- Describe the management of breech presentation.
- Explain the diagnosis and management of transverse lie and shoulder presentation.
- Describe the indications for external cephalic version.
Clinical vignettes
- On abdominal examination at 36 weeks, the fetal head is palpated in the fundus and the breech in the pelvis. Dx: Breech presentation.
- A woman in labour has a prolonged first stage with the fetal occiput persistently posterior. Dx: Occipitoposterior position.
Menopause & Perimenopausal Disorders
- Describe the physiology and clinical features of menopause.
- Explain the diagnosis and management of perimenopausal bleeding.
- Describe the indications and risks of hormone replacement therapy.
- Explain the long-term health consequences of menopause.
- Describe the non-hormonal management of menopausal symptoms.
Clinical vignettes
- A 50-year-old woman presents with hot flashes, night sweats, and irregular cycles over the past year. Dx: Perimenopausal syndrome.
- A postmenopausal woman on long-term estrogen therapy is evaluated for the risks and benefits of continuing hormone replacement therapy. Point: illustrates HRT risk-benefit counseling.

Paediatrics

Growth & Development
- Assess growth using standard growth charts.
- Describe the normal developmental milestones in children.
- Explain the causes and evaluation of failure to thrive.
- Describe the assessment of developmental delay.
- Explain factors affecting normal growth and development.
Clinical vignettes
- A 2-year-old's weight and height are plotted on a growth chart and found below the 3rd percentile. Dx: Failure to thrive — needs evaluation.
- A 9-month-old cannot sit without support and shows no response to name. Dx: Developmental delay — needs assessment.
Newborn Care & Neonatology
- Perform initial assessment and resuscitation of a newborn.
- Describe the routine care of a normal newborn.
- Explain the diagnosis and management of neonatal jaundice.
- Describe the management of a preterm and low birth weight infant.
- Explain the diagnosis and management of neonatal sepsis.
Clinical vignettes
- A newborn develops poor feeding, lethargy, and temperature instability on day 3 of life. Dx: Neonatal sepsis.
- A preterm baby develops respiratory distress with grunting and retractions shortly after birth. Dx: Respiratory distress syndrome (surfactant deficiency).
Nutrition & Nutritional Disorders in Children
- Describe the principles of infant and young child feeding.
- Explain the diagnosis and management of protein-energy malnutrition.
- Describe the management of micronutrient deficiency disorders in children.
- Explain the WHO classification of malnutrition.
- Describe complementary feeding practices.
Clinical vignettes
- A 2-year-old presents with bilateral pitting pedal edema, thin sparse hair, and a distended abdomen. Dx: Kwashiorkor.
- A severely wasted infant with visible ribs and loose skin folds is brought in. Dx: Marasmus.
Immunization
- Describe the national immunization schedule.
- Explain the storage and administration of vaccines.
- Describe the contraindications and adverse effects of vaccines.
- Explain the concept of cold chain maintenance.
- Describe catch-up immunization schedules.
Clinical vignettes
- A mother brings her 6-week-old infant for scheduled vaccines. Point: illustrates the national immunization schedule.
- A 3-year-old who missed vaccines due to migration needs a catch-up schedule. Point: illustrates catch-up immunization planning.
Fluid, Electrolyte & Nutritional Rehabilitation
- Describe fluid and electrolyte management in a sick child.
- Explain the assessment and management of dehydration.
- Describe the principles of nutritional rehabilitation in severe malnutrition.
- Explain the use of oral rehydration therapy.
- Describe the management of electrolyte imbalances in children.
Clinical vignettes
- A child with severe watery diarrhea presents with sunken eyes, lethargy, and a very slow skin pinch. Dx: Severe dehydration.
- A malnourished child undergoing nutritional rehabilitation develops sudden heart failure after aggressive refeeding. Dx: Refeeding syndrome.
Infectious Diseases in Children
- Describe the diagnosis and management of common childhood infections.
- Explain the diagnosis and management of pediatric tuberculosis.
- Describe the approach to a febrile child.
- Explain the management of common exanthematous fevers.
- Describe the diagnosis and management of pediatric HIV.
Clinical vignettes
- A 4-year-old presents with high fever, a rash starting on the face, and conjunctivitis. Dx: Measles.
- A 6-year-old presents with fever, sore throat, and a diffuse fine sandpaper-like rash. Dx: Scarlet fever.
Respiratory Disorders
- Describe the diagnosis and management of pneumonia in children.
- Explain the diagnosis and management of bronchiolitis.
- Describe the diagnosis and management of childhood asthma.
- Explain the approach to a child with respiratory distress.
- Describe the management of croup and epiglottitis.
Clinical vignettes
- An 18-month-old presents with barking cough, stridor, and hoarse voice, worse at night. Dx: Croup (laryngotracheobronchitis).
- A 3-year-old presents with high fever, drooling, and preferring to sit leaning forward. Dx: Acute epiglottitis — emergency.
Cardiovascular Disorders & Congenital Heart Disease
- Describe the clinical presentation of common congenital heart diseases.
- Explain the approach to a child with cyanosis.
- Describe the diagnosis and management of rheumatic fever.
- Explain the management of congestive heart failure in children.
- Describe the indications for referral in congenital heart disease.
Clinical vignettes
- A newborn is noted to be cyanotic with a harsh systolic murmur; echo confirms a cardiac defect. Dx: Tetralogy of Fallot (cyanotic CHD).
- An infant has recurrent chest infections, poor feeding, and a continuous murmur at the left upper sternal border. Dx: Patent ductus arteriosus.
Gastrointestinal Disorders
- Describe the diagnosis and management of acute diarrhea in children.
- Explain the approach to a child with chronic diarrhea.
- Describe the diagnosis and management of common surgical GI conditions in children.
- Explain the approach to a child with abdominal pain.
- Describe the management of GI parasitic infections.
Clinical vignettes
- A 3-week-old boy has projectile non-bilious vomiting after every feed with visible peristalsis. Dx: Hypertrophic pyloric stenosis.
- A 6-month-old has recurrent colicky abdominal pain, drawing up of legs, and red currant jelly stools. Dx: Intussusception.
Renal & Urinary Disorders
- Describe the diagnosis and management of nephrotic syndrome in children.
- Explain the diagnosis and management of acute glomerulonephritis.
- Describe the diagnosis and management of urinary tract infection in children.
- Explain the approach to a child with hematuria.
- Describe the management of acute kidney injury in children.
Clinical vignettes
- A 5-year-old develops facial puffiness, cola-colored urine, and hypertension a week after a sore throat. Dx: Post-streptococcal acute glomerulonephritis.
- A 3-year-old presents with generalized edema and heavy proteinuria with normal blood pressure. Dx: Minimal change nephrotic syndrome.
Hematological Disorders
- Describe the diagnosis and management of anemia in children.
- Explain the diagnosis and management of childhood leukemia.
- Describe the diagnosis and management of hemophilia.
- Explain the approach to a child with bleeding manifestations.
- Describe the management of thalassemia.
Clinical vignettes
- A 1-year-old presents with pallor, growth failure, and hepatosplenomegaly; hemoglobin electrophoresis shows raised HbF. Dx: Beta-thalassemia major.
- A 3-year-old boy presents with excessive bruising and hemarthrosis after a minor fall. Dx: Hemophilia.
Neurological Disorders
- Describe the diagnosis and management of febrile seizures.
- Explain the diagnosis and management of childhood epilepsy.
- Describe the approach to a child with developmental regression.
- Explain the diagnosis and management of cerebral palsy.
- Describe the approach to a child with acute encephalopathy.
Clinical vignettes
- A 6-month-old presents with recurrent brief flexor spasms in clusters, with regression of milestones. Dx: Infantile spasms (West syndrome).
- A 2-year-old presents with fever, neck stiffness, bulging fontanelle, and irritability. Dx: Acute bacterial meningitis.
Endocrine & Metabolic Disorders
- Describe the diagnosis and management of type 1 diabetes mellitus in children.
- Explain the approach to a child with short stature.
- Describe the diagnosis and management of congenital hypothyroidism.
- Explain the approach to ambiguous genitalia.
- Describe the screening for inborn errors of metabolism.
Clinical vignettes
- A newborn on routine screening has a raised TSH with normal T4. Dx: Congenital hypothyroidism — needs urgent treatment to prevent developmental delay.
- A neonate develops poor feeding, vomiting, and lethargy after starting milk feeds, with an unusual odor to the urine. Dx: Suspected inborn error of metabolism (e.g., maple syrup urine disease).
Genetic Disorders & Congenital Malformations
- Describe the clinical features of common chromosomal disorders.
- Explain the approach to a child with dysmorphic features.
- Describe the diagnosis and counseling for genetic disorders.
- Explain the principles of antenatal diagnosis of congenital anomalies.
- Describe the management approach to common birth defects.
Clinical vignettes
- A newborn has upward slanting eyes, a single palmar crease, and hypotonia. Dx: Down syndrome (Trisomy 21).
- A newborn has a midline defect over the lower back with an underlying meningeal sac. Dx: Spina bifida (meningomyelocele).
Behavioral & Developmental Pediatrics
- Describe the assessment of common behavioral problems in children.
- Explain the diagnosis and management of attention deficit hyperactivity disorder.
- Describe the identification and management of autism spectrum disorder.
- Explain the approach to learning disabilities.
- Describe strategies for positive parenting guidance.
Clinical vignettes
- A 3-year-old boy has poor eye contact, delayed speech, and repetitive hand-flapping movements. Dx: Autism spectrum disorder.
- A 7-year-old has difficulty sitting still, is easily distracted, and impulsive both at home and school. Dx: Attention-deficit/hyperactivity disorder.
Pediatric Emergencies & Critical Care
- Perform pediatric basic life support.
- Describe the recognition and management of shock in children.
- Explain the management of status epilepticus in children.
- Describe the approach to a critically ill child.
- Explain the principles of pediatric triage.
Clinical vignettes
- A choking 2-year-old suddenly cannot cry or cough and turns cyanotic. Point: illustrates need for immediate pediatric foreign-body airway management.
- A febrile child presents with a single generalized seizure lasting 3 minutes that stops spontaneously. Dx: Simple febrile seizure.
Social & Community Pediatrics
- Describe the impact of social determinants on child health.
- Explain the recognition and management of child abuse and neglect.
- Describe national programmes for child health.
- Explain the role of school health services.
- Describe strategies for community-based management of childhood illness.
Clinical vignettes
- A community health worker uses IMNCI guidelines to assess a sick young infant. Point: illustrates integrated management of neonatal and childhood illness.
- A child from a low-income family presents with recurrent respiratory infections linked to indoor air pollution and overcrowding. Point: illustrates social determinants of child health.
Adolescent Medicine
- Describe the physical and psychosocial changes of adolescence.
- Explain the approach to common adolescent health problems.
- Describe the assessment and management of adolescent reproductive health issues.
- Explain the recognition of risk-taking behavior in adolescents.
- Describe strategies for adolescent-friendly health services.
Clinical vignettes
- A 15-year-old girl presents confidentially with concerns about delayed menarche. Point: illustrates adolescent-friendly, confidential counseling.
- A 16-year-old boy is brought by his parents for risk-taking behavior and substance experimentation. Point: illustrates adolescent psychosocial assessment (HEADSS).
Pediatric HIV & AIDS
- Describe the modes of transmission of HIV in children.
- Explain the diagnosis of HIV infection in infants and children.
- Describe the principles of antiretroviral therapy in children.
- Explain the prevention of mother-to-child transmission of HIV.
- Describe the management of opportunistic infections in HIV-infected children.
Clinical vignettes
- An infant born to an HIV-positive mother is started on prophylactic antiretroviral therapy at birth. Point: illustrates prevention of mother-to-child transmission.
- An HIV-infected child presents with chronic cough, fever, and oral thrush unresponsive to standard treatment. Dx: Opportunistic infection in pediatric HIV/AIDS.

Orthopaedics

Basic Sciences — Bone, Joint & Fracture Healing
- Describe the structure and physiology of bone.
- Explain the stages of fracture healing.
- Describe the classification of joints and their biomechanics.
- Explain factors affecting fracture healing.
- Describe the principles of bone remodeling.
Clinical vignettes
- A postmenopausal woman sustains a distal radius fracture after a minor fall. Point: illustrates a fragility fracture due to reduced bone density.
- An X-ray of a healing fracture at 6 weeks shows callus formation bridging the fracture line. Point: illustrates normal fracture healing stages.
Principles of Fracture Management
- Describe the classification of fractures.
- Explain the principles of fracture reduction and immobilization.
- Describe the indications for conservative versus operative management.
- Explain the complications of fractures and their management.
- Describe the principles of internal and external fixation.
Clinical vignettes
- A young man with an open tibial fracture after a road accident is managed with debridement and external fixation. Point: illustrates open fracture management principles.
- An elderly woman with an intertrochanteric femur fracture undergoes internal fixation with a dynamic hip screw. Point: illustrates fixation choice by fracture pattern.
Upper Limb Trauma
- Describe the diagnosis and management of common upper limb fractures.
- Explain the management of shoulder dislocation.
- Describe the diagnosis and management of elbow injuries.
- Explain the management of wrist and hand fractures.
- Describe complications specific to upper limb trauma.
Clinical vignettes
- A child falls on an outstretched hand and presents with a swollen, deformed elbow and an absent radial pulse. Dx: Supracondylar fracture of the humerus with vascular compromise.
- After a mid-shaft humerus fracture, a patient cannot extend the wrist and fingers. Dx: Radial nerve injury (wrist drop).
Lower Limb Trauma
- Describe the diagnosis and management of common lower limb fractures.
- Explain the management of hip fractures and dislocations.
- Describe the diagnosis and management of knee ligament injuries.
- Explain the management of ankle and foot fractures.
- Describe complications specific to lower limb trauma.
Clinical vignettes
- A young man on a motorcycle sustains a closed femoral shaft fracture with a tense, painful thigh. Point: raises concern for compartment syndrome/fat embolism.
- An elderly woman after a fall presents with a shortened, externally rotated, and adducted lower limb. Dx: Fracture neck of femur.
Spine Trauma & Disorders
- Describe the initial assessment of a patient with suspected spinal injury.
- Explain the classification and management of spinal fractures.
- Describe the diagnosis and management of common spinal disorders (e.g., disc prolapse).
- Explain the assessment of spinal cord injury.
- Describe the principles of spinal immobilization.
Clinical vignettes
- A man after a diving accident presents with loss of motor and sensory function below the neck. Dx: Cervical spinal cord injury.
- An elderly osteoporotic patient presents with back pain and sudden loss of height after a minor fall. Dx: Osteoporotic vertebral compression fracture.
Pelvic & Acetabular Injuries
- Describe the classification of pelvic fractures.
- Explain the initial management of a patient with pelvic trauma.
- Describe the complications of pelvic fractures.
- Explain the approach to acetabular fractures.
- Describe the indications for surgical fixation of pelvic injuries.
Clinical vignettes
- A patient after a high-speed collision presents with pelvic instability and hypotension. Dx: Unstable pelvic fracture with hemorrhage — life-threatening.
- A patient sustains a fall directly onto the hip with the femur driven into the pelvis. Dx: Acetabular fracture.
Joint Dislocations
- Describe the diagnosis and management of shoulder dislocation.
- Explain the management of hip dislocation.
- Describe the diagnosis and management of knee dislocation.
- Explain the complications of joint dislocations.
- Describe the principles of closed reduction techniques.
Clinical vignettes
- A young man falls on an outstretched abducted arm and presents with a flattened shoulder contour and inability to move the arm. Dx: Anterior shoulder dislocation.
- A patient after a dashboard injury in a road accident presents with a flexed, adducted, internally rotated hip. Dx: Posterior hip dislocation.
Bone & Joint Infections
- Describe the diagnosis and management of acute osteomyelitis.
- Explain the diagnosis and management of septic arthritis.
- Describe the diagnosis and management of tuberculosis of bone and joint.
- Explain the approach to chronic osteomyelitis.
- Describe the principles of antibiotic therapy in bone infections.
Clinical vignettes
- A child presents with high fever, severe pain, and refusal to move one limb, with local warmth and swelling near a long bone. Dx: Acute hematogenous osteomyelitis.
- A patient has a chronically discharging sinus over a previously fractured bone. Dx: Chronic osteomyelitis.
Bone Tumors
- Describe the classification of primary bone tumors.
- Explain the clinical and radiological features of common bone tumors.
- Describe the approach to a patient with a suspected bone tumor.
- Explain the principles of biopsy in bone tumors.
- Describe the management of metastatic bone disease.
Clinical vignettes
- A teenager presents with progressive knee pain and swelling, with X-ray showing a "sunburst" periosteal reaction. Dx: Osteosarcoma.
- An elderly man with known prostate cancer develops new severe back pain; X-ray shows sclerotic bone lesions. Dx: Metastatic bone disease.
Metabolic Bone Disease
- Describe the diagnosis and management of osteoporosis.
- Explain the diagnosis and management of rickets and osteomalacia.
- Describe the orthopedic manifestations of hyperparathyroidism.
- Explain the approach to a patient with pathological fracture.
- Describe the role of bone density scanning.
Clinical vignettes
- An elderly woman sustains a fracture after a trivial fall; DEXA scan shows a T-score of -3.0. Dx: Osteoporosis.
- A child presents with bowing of the legs, delayed walking, and widened wrist joints. Dx: Rickets.
Pediatric Orthopedics & Congenital Deformities
- Describe the diagnosis and management of developmental dysplasia of hip.
- Explain the management of clubfoot.
- Describe the diagnosis and management of common pediatric limb deformities.
- Explain the approach to limb length discrepancy.
- Describe the management of pediatric fractures.
Clinical vignettes
- A newborn is noted to have asymmetric thigh folds and a positive Ortolani/Barlow test. Dx: Developmental dysplasia of the hip.
- A 2-year-old presents with a rigid, medially deviated foot noted since birth. Dx: Congenital talipes equinovarus (clubfoot).
Degenerative Joint Disease & Arthroplasty
- Describe the diagnosis and management of osteoarthritis.
- Explain the indications for joint replacement surgery.
- Describe the complications of arthroplasty.
- Explain the principles of rehabilitation after joint replacement.
- Describe the conservative management options for degenerative joint disease.
Clinical vignettes
- A 65-year-old obese woman presents with knee pain worse with activity and morning stiffness lasting less than 30 minutes. Dx: Osteoarthritis of the knee.
- An elderly patient with severe disabling hip osteoarthritis unresponsive to conservative treatment is planned for total hip replacement. Point: illustrates indication for arthroplasty.
Sports Injuries & Arthroscopy
- Describe the diagnosis and management of common sports injuries.
- Explain the indications for arthroscopic surgery.
- Describe the management of meniscal and ligamentous knee injuries.
- Explain the principles of sports injury rehabilitation.
- Describe the prevention strategies for sports-related injuries.
Clinical vignettes
- A young footballer twists his knee, hears a pop, and develops swelling and instability. Dx: Anterior cruciate ligament tear.
- A basketball player has recurrent shoulder dislocations during overhead movements. Dx: Recurrent shoulder instability.
Peripheral Nerve Injuries
- Describe the classification of peripheral nerve injuries.
- Explain the clinical assessment of common nerve injuries.
- Describe the management options for nerve injury.
- Explain the expected recovery patterns following nerve injury.
- Describe the role of nerve conduction studies in diagnosis.
Clinical vignettes
- A patient after prolonged pressure over the outer knee (e.g., a plaster cast) develops foot drop. Dx: Common peroneal nerve palsy.
- A patient presents with numbness of the lateral 3½ fingers and thenar wasting, worse at night. Dx: Carpal tunnel syndrome (median nerve compression).
Amputations & Rehabilitation
- Describe the indications for amputation.
- Explain the levels and techniques of amputation.
- Describe the principles of prosthetic rehabilitation.
- Explain the management of phantom limb pain.
- Describe the psychosocial aspects of amputation.
Clinical vignettes
- A diabetic patient with a gangrenous foot undergoes below-knee amputation. Point: illustrates indications and level selection for amputation.
- A patient after limb amputation reports persistent pain sensation in the missing limb. Dx: Phantom limb pain.
Orthopedic Emergencies
- Describe the recognition and management of compartment syndrome.
- Explain the management of open fractures.
- Describe the approach to a patient with fat embolism syndrome.
- Explain the management of neurovascular injury in trauma.
- Describe the initial management of a polytrauma patient with orthopedic injuries.
Clinical vignettes
- A patient with a tibial fracture develops severe pain out of proportion, pain on passive stretch, and tense swelling of the leg. Dx: Compartment syndrome — surgical emergency.
- A patient with an open fracture and a heavily contaminated wound is assessed for urgent debridement. Point: illustrates open fracture emergency management.
Disorders of the Hand & Foot
- Describe the common congenital and acquired deformities of the hand.
- Explain the diagnosis and management of common foot deformities.
- Describe the management of diabetic foot.
- Explain the approach to a patient with hand trauma.
- Describe the common tendon and nerve injuries of the hand.
Clinical vignettes
- A patient with a palm laceration is unable to flex the fingertip at the distal joint. Dx: Flexor digitorum profundus tendon injury.
- A middle-aged patient presents with progressive flexion contracture of the ring and little fingers. Dx: Dupuytren's contracture.
Prosthetics, Orthotics & Assistive Devices
- Describe the principles of prosthetic fitting after amputation.
- Explain the indications for common orthotic devices.
- Describe the role of assistive devices in mobility rehabilitation.
- Explain the team approach to prosthetic and orthotic rehabilitation.
- Describe the complications associated with prosthetic use.
Clinical vignettes
- A below-knee amputee develops skin breakdown at the prosthetic socket contact area. Point: illustrates prosthetic fitting complications.
- A child with cerebral palsy is fitted with an ankle-foot orthosis to improve gait. Point: illustrates orthotic use in pediatric rehabilitation.

Ophthalmology

Anatomy & Physiology of the Eye
- Describe the anatomy of the eyeball and its layers.
- Explain the physiology of aqueous humor formation and drainage.
- Describe the anatomy of the visual pathway.
- Explain the accommodation and pupillary reflex mechanisms.
- Describe the blood supply and innervation of the eye.
Clinical vignettes
- A patient with sudden painless loss of vision is found to have a pale retina with a cherry-red spot on fundoscopy. Dx: Central retinal artery occlusion.
- A patient with diplopia and ptosis is found to have a dilated, non-reactive pupil. Point: illustrates localization of third cranial nerve palsy.
Optics & Refraction
- Describe the principles of ocular optics.
- Explain the types and correction of refractive errors.
- Describe the procedure for visual acuity testing.
- Explain the principles of prescribing spectacles and contact lenses.
- Describe the diagnosis and management of presbyopia.
Clinical vignettes
- A 45-year-old with previously normal vision now has difficulty reading fine print up close. Dx: Presbyopia.
- A child struggles to see the blackboard clearly from the back of the classroom. Dx: Myopia — needs refraction correction.
Diseases of the Eyelids & Lacrimal Apparatus
- Describe the diagnosis and management of common eyelid infections.
- Explain the diagnosis and management of ptosis.
- Describe the causes and management of epiphora.
- Explain the diagnosis and management of dacryocystitis.
- Describe common eyelid malpositions and their management.
Clinical vignettes
- A patient presents with a painful red swelling at the eyelid margin near the eyelash line. Dx: Stye (external hordeolum).
- An elderly patient has the eyelid margin turned inward with lashes rubbing against the cornea. Dx: Entropion.
Conjunctiva & Cornea Disorders
- Describe the diagnosis and management of conjunctivitis.
- Explain the diagnosis and management of corneal ulcers.
- Describe the approach to a red eye.
- Explain the management of corneal foreign bodies and abrasions.
- Describe the diagnosis and management of keratitis.
Clinical vignettes
- A patient presents with redness, watering, and mucopurulent discharge in one eye that spreads to the other. Dx: Bacterial conjunctivitis.
- A contact lens wearer presents with severe eye pain, photophobia, and a white corneal opacity. Dx: Microbial keratitis (corneal ulcer).
Sclera & Uveal Tract Disorders
- Describe the diagnosis and management of scleritis and episcleritis.
- Explain the diagnosis and management of anterior uveitis.
- Describe the systemic associations of uveitis.
- Explain the complications of uveitis.
- Describe the approach to a patient with painful red eye and photophobia.
Clinical vignettes
- A young adult presents with painful red eye, photophobia, and a small irregular pupil with circumcorneal congestion. Dx: Acute anterior uveitis.
- A patient presents with localized painful redness of the eye with a bluish-red hue over the sclera. Dx: Scleritis.
Cataract & Lens Disorders
- Describe the classification and clinical features of cataract.
- Explain the indications and techniques for cataract surgery.
- Describe the complications of cataract surgery.
- Explain the management of congenital cataract.
- Describe the postoperative care following cataract surgery.
Clinical vignettes
- An elderly patient presents with gradual, painless blurring of vision and a whitish pupillary reflex. Dx: Age-related cataract.
- A patient a few days after cataract surgery presents with sudden pain, redness, and reduced vision. Dx: Postoperative endophthalmitis — emergency.
Glaucoma
- Describe the classification and pathophysiology of glaucoma.
- Explain the diagnosis and screening for glaucoma.
- Describe the medical and surgical management of glaucoma.
- Explain the diagnosis and emergency management of acute angle closure glaucoma.
- Describe the follow-up and monitoring of glaucoma patients.
Clinical vignettes
- A patient presents with sudden severe eye pain, headache, vomiting, and a mid-dilated fixed pupil with a hard eyeball. Dx: Acute angle-closure glaucoma.
- An elderly patient is found on routine screening to have gradually progressive peripheral vision loss with raised intraocular pressure. Dx: Primary open-angle glaucoma.
Vitreous & Retinal Disorders
- Describe the diagnosis and management of diabetic retinopathy.
- Explain the diagnosis and management of retinal detachment.
- Describe the diagnosis and management of age-related macular degeneration.
- Explain the approach to a patient with sudden visual loss.
- Describe the diagnosis and management of hypertensive retinopathy.
Clinical vignettes
- A patient with long-standing diabetes presents with gradually worsening vision; fundoscopy shows microaneurysms and hemorrhages. Dx: Diabetic retinopathy.
- A patient describes sudden flashes of light, floaters, and a curtain-like shadow over part of the visual field. Dx: Retinal detachment.
Neuro-ophthalmology & Optic Nerve Disorders
- Describe the diagnosis and management of optic neuritis.
- Explain the approach to a patient with papilledema.
- Describe the diagnosis and management of optic atrophy.
- Explain the assessment of visual field defects and their localization.
- Describe the neuro-ophthalmic examination.
Clinical vignettes
- A young woman presents with sudden painful loss of vision in one eye, worse with eye movement. Dx: Optic neuritis.
- A patient with a brain tumor is found to have bilateral optic disc swelling on fundoscopy. Dx: Papilledema due to raised intracranial pressure.
Strabismus & Ocular Motility
- Describe the classification and diagnosis of strabismus.
- Explain the management of amblyopia.
- Describe the assessment of ocular motility.
- Explain the indications for surgical correction of strabismus.
- Describe the approach to a child with squint.
Clinical vignettes
- A parent notices their 3-year-old's eyes are not aligned, with one eye turning inward. Dx: Convergent squint (esotropia) — needs early correction to prevent amblyopia.
- A child fails to develop clear vision in one eye despite a normal eye exam, due to a long-standing untreated squint. Dx: Amblyopia.
Orbital Diseases
- Describe the diagnosis and management of orbital cellulitis.
- Explain the approach to a patient with proptosis.
- Describe the diagnosis and management of thyroid eye disease.
- Explain the approach to orbital trauma.
- Describe common orbital tumors and their presentation.
Clinical vignettes
- A child presents with rapidly progressive proptosis, redness, pain, and fever. Dx: Orbital cellulitis.
- A patient with thyroid disease presents with bilateral bulging eyes and lid retraction. Dx: Thyroid eye disease (Graves' ophthalmopathy).
Ocular Trauma & Emergencies
- Describe the initial management of ocular chemical injury.
- Explain the management of a penetrating eye injury.
- Describe the approach to a patient with sudden loss of vision.
- Explain the management of ocular foreign bodies.
- Describe the indications for emergency ophthalmic referral.
Clinical vignettes
- A patient presents after a chemical splash to the eye with severe pain and blurred vision. Point: illustrates the need for immediate copious irrigation before any other treatment.
- A patient sustains a penetrating eye injury from a metal fragment while hammering. Dx: Open globe injury — surgical emergency.
Community Ophthalmology & Blindness Control
- Describe the causes and prevention of avoidable blindness.
- Explain the national programme for control of blindness.
- Describe the principles of community eye screening.
- Explain the role of primary eye care in the community.
- Describe strategies for prevention of childhood blindness.
Clinical vignettes
- A community vision screening camp identifies several children with uncorrected refractive errors. Point: illustrates the role of school eye screening programs.
- A malnourished child presents with night blindness and dry, foamy patches on the conjunctiva. Dx: Vitamin A deficiency (xerophthalmia).

Otorhinolaryngology (ENT)

Anatomy & Physiology of Ear, Nose & Throat
- Describe the anatomy of the external, middle, and inner ear.
- Explain the anatomy and physiology of the nose and paranasal sinuses.
- Describe the anatomy of the pharynx and larynx.
- Explain the physiology of hearing and balance.
- Describe the anatomical basis of common ENT clinical examinations.
Clinical vignettes
- A patient with reduced hearing undergoes Rinne and Weber tuning fork tests to differentiate conductive from sensorineural loss. Point: illustrates clinical application of ENT anatomy.
- An otoscopic exam is performed to visualize the tympanic membrane in a patient with ear pain. Point: illustrates standard ENT examination technique.
Diseases of the External & Middle Ear
- Describe the diagnosis and management of otitis externa.
- Explain the diagnosis and management of acute and chronic otitis media.
- Describe the complications of middle ear infections.
- Explain the management of tympanic membrane perforation.
- Describe the surgical options for chronic ear disease.
Clinical vignettes
- A child presents with ear pain, fever, and a bulging red tympanic membrane after an upper respiratory infection. Dx: Acute otitis media.
- A patient with long-standing ear discharge has a central tympanic membrane perforation. Dx: Chronic suppurative otitis media.
Diseases of the Inner Ear & Hearing Loss
- Describe the classification and evaluation of hearing loss.
- Explain the diagnosis and management of sensorineural hearing loss.
- Describe the diagnosis and management of Meniere's disease.
- Explain the indications for hearing aids and cochlear implants.
- Describe the approach to sudden sensorineural hearing loss.
Clinical vignettes
- A patient presents with episodic vertigo, tinnitus, and fluctuating hearing loss. Dx: Ménière's disease.
- An elderly patient reports progressive bilateral hearing loss, worse for high-pitched sounds. Dx: Presbycusis.
Diseases of the Nose & Paranasal Sinuses
- Describe the diagnosis and management of allergic rhinitis.
- Explain the diagnosis and management of sinusitis.
- Describe the diagnosis and management of nasal polyps.
- Explain the management of epistaxis.
- Describe the approach to nasal obstruction.
Clinical vignettes
- A patient presents with facial pain, purulent nasal discharge, and fever after a cold that hasn't resolved in 2 weeks. Dx: Acute bacterial sinusitis.
- A young adult has persistent one-sided nasal obstruction with a fleshy, pale, insensitive mass on examination. Dx: Nasal polyp.
Diseases of the Oral Cavity & Pharynx
- Describe the diagnosis and management of tonsillitis and its complications.
- Explain the approach to a patient with a sore throat.
- Describe the diagnosis and management of adenoid hypertrophy.
- Explain the diagnosis and management of oral cavity and pharyngeal lesions.
- Describe the indications for tonsillectomy and adenoidectomy.
Clinical vignettes
- A child presents with recurrent sore throat, fever, and enlarged tonsils with exudate. Dx: Recurrent acute tonsillitis — evaluate for tonsillectomy.
- A young adult presents with severe unilateral throat pain, trismus, and a muffled "hot potato" voice. Dx: Peritonsillar abscess (quinsy).
Diseases of the Larynx
- Describe the diagnosis and management of laryngitis.
- Explain the approach to a patient with hoarseness of voice.
- Describe the diagnosis and management of vocal cord nodules and polyps.
- Explain the approach to laryngeal carcinoma.
- Describe the indications for tracheostomy.
Clinical vignettes
- A patient presents with progressive hoarseness of voice for 3 months, a smoking history, and a neck mass. Dx: Suspected laryngeal carcinoma.
- A patient with stridor and worsening breathing difficulty is planned for an emergency tracheostomy. Point: illustrates airway emergency management.
Head & Neck Tumors
- Describe the diagnosis and evaluation of a neck mass.
- Explain the staging of head and neck cancers.
- Describe the diagnosis and management of nasopharyngeal carcinoma.
- Explain the multidisciplinary management of head and neck malignancies.
- Describe the follow-up care of head and neck cancer patients.
Clinical vignettes
- An elderly tobacco chewer presents with a non-healing ulcer on the lateral border of the tongue. Dx: Suspected oral cavity carcinoma.
- A patient presents with a painless enlarging neck node found to be metastatic squamous cell carcinoma with no obvious primary. Dx: Occult primary head and neck malignancy — needs further workup.
Salivary Gland Disorders
- Describe the diagnosis and management of sialadenitis.
- Explain the diagnosis and management of salivary gland calculi.
- Describe the approach to a salivary gland swelling.
- Explain the classification of salivary gland tumors.
- Describe the surgical management of salivary gland disorders.
Clinical vignettes
- A patient presents with painful swelling below the jaw that worsens while eating. Dx: Salivary gland (submandibular) calculus.
- A patient presents with a slow-growing, painless swelling in front of the ear. Dx: Pleomorphic adenoma of the parotid gland.
ENT Emergencies & Foreign Bodies
- Describe the management of foreign bodies in the ear, nose, and throat.
- Explain the emergency management of epistaxis.
- Describe the management of stridor in a child.
- Explain the emergency management of a patient with airway obstruction.
- Describe the initial management of facial and neck trauma.
Clinical vignettes
- A toddler suddenly develops choking, coughing, and stridor while playing with small toys. Dx: Suspected foreign body aspiration.
- A patient presents with profuse nosebleed after trauma, unresponsive to simple pressure. Dx: Severe epistaxis — needs nasal packing/further management.
Audiology & Vestibular Disorders
- Describe the common audiometric tests and their interpretation.
- Explain the assessment of a patient with vertigo.
- Describe the diagnosis and management of benign paroxysmal positional vertigo.
- Explain the principles of vestibular rehabilitation.
- Describe the role of audiological evaluation in hearing loss diagnosis.
Clinical vignettes
- A newborn fails the routine otoacoustic emission hearing screening test. Point: illustrates the importance of universal newborn hearing screening.
- A patient presents with sudden severe spinning vertigo, nausea, and vomiting after a viral illness, without hearing loss. Dx: Vestibular neuritis.
ENT Manifestations of Systemic Disease
- Describe the ENT manifestations of granulomatous diseases.
- Explain the ENT complications of diabetes mellitus.
- Describe the ENT manifestations of HIV infection.
- Explain the ENT features of autoimmune disorders.
- Describe the approach to a patient with systemic disease presenting with ENT symptoms.
Clinical vignettes
- A patient with poorly controlled diabetes presents with severe ear pain, discharge, and granulation tissue in the ear canal. Dx: Malignant otitis externa.
- A patient with granulomatosis with polyangiitis presents with nasal crusting, epistaxis, and saddle nose deformity. Point: illustrates an ENT manifestation of systemic vasculitis.

Dermatology, Venereology & Leprosy

Structure & Function of Skin
- Describe the structure and functions of the layers of the skin.
- Explain the physiology of skin appendages.
- Describe the basic principles of skin barrier function.
- Explain the process of wound healing in the skin.
- Describe the changes in skin with age.
Clinical vignettes
- An elderly patient presents with thin, wrinkled skin with easy bruising after minor trauma. Point: illustrates age-related skin changes.
- A patient's skin biopsy is examined to identify the layer of origin of a suspicious lesion. Point: illustrates the clinical relevance of skin histology.
Approach to Dermatological Diagnosis
- Describe the systematic approach to examining a skin lesion.
- Explain the terminology used to describe primary and secondary skin lesions.
- Describe the common diagnostic procedures used in dermatology.
- Explain the principles of skin biopsy.
- Describe the use of dermoscopy in clinical diagnosis.
Clinical vignettes
- A patient presents with a pigmented lesion; dermoscopy is used to differentiate a benign nevus from melanoma. Point: illustrates diagnostic approach to pigmented lesions.
- A dermatologist systematically describes a rash by its morphology, distribution, and configuration before reaching a diagnosis. Point: illustrates the standard dermatological diagnostic approach.
Infective Dermatoses — Bacterial & Fungal
- Describe the diagnosis and management of common bacterial skin infections.
- Explain the diagnosis and management of superficial and deep fungal infections.
- Describe the approach to a patient with impetigo or cellulitis.
- Explain the principles of antimicrobial therapy in skin infections.
- Describe preventive measures for infective dermatoses.
Clinical vignettes
- A child presents with honey-colored crusted lesions around the mouth and nose. Dx: Impetigo.
- A patient presents with an itchy, ring-shaped, scaly lesion with central clearing on the trunk. Dx: Tinea corporis (dermatophytosis).
Infective Dermatoses — Viral & Parasitic
- Describe the diagnosis and management of common viral skin infections.
- Explain the diagnosis and management of scabies and pediculosis.
- Describe the clinical features of herpes simplex and herpes zoster.
- Explain the management of molluscum contagiosum and warts.
- Describe preventive strategies for parasitic skin infestations.
Clinical vignettes
- A patient presents with painful grouped vesicles on an erythematous base in a unilateral dermatomal distribution. Dx: Herpes zoster.
- A patient presents with intense itching, worse at night, with burrows between the finger webs and similar complaints in family members. Dx: Scabies.
Eczema & Papulosquamous Disorders
- Describe the diagnosis and management of atopic dermatitis.
- Explain the diagnosis and management of psoriasis.
- Describe the diagnosis and management of contact dermatitis.
- Explain the approach to a patient with chronic itching.
- Describe the classification of papulosquamous disorders.
Clinical vignettes
- A patient presents with well-demarcated, silvery scaly plaques over the extensor surfaces of the elbows and knees. Dx: Psoriasis.
- An infant presents with itchy, red, scaly patches on the face and flexural areas. Dx: Atopic dermatitis (infantile eczema).
Vesiculobullous Disorders
- Describe the diagnosis and management of pemphigus.
- Explain the diagnosis and management of bullous pemphigoid.
- Describe the approach to a patient with blistering skin lesions.
- Explain the role of immunofluorescence in diagnosis of bullous disorders.
- Describe the management of Stevens-Johnson syndrome and toxic epidermal necrolysis.
Clinical vignettes
- A patient develops flaccid blisters and erosions on skin and oral mucosa; Nikolsky's sign is positive. Dx: Pemphigus vulgaris.
- A patient develops fever, target lesions, and mucosal erosions with widespread skin detachment days after starting a new drug. Dx: Stevens-Johnson syndrome/toxic epidermal necrolysis.
Disorders of Pigmentation
- Describe the diagnosis and management of vitiligo.
- Explain the causes and management of hyperpigmentation disorders.
- Describe the approach to a patient with hypopigmented lesions.
- Explain the counseling required for pigmentary disorders.
- Describe the psychosocial impact of pigmentary disorders.
Clinical vignettes
- A young adult presents with well-defined depigmented patches on the hands and face. Dx: Vitiligo.
- A woman presents with symmetrical brownish patches on both cheeks, worsened by sun exposure. Dx: Melasma.
Acne, Rosacea & Disorders of Sebaceous Glands
- Describe the pathogenesis and management of acne vulgaris.
- Explain the diagnosis and management of rosacea.
- Describe the classification of acne severity.
- Explain the use of topical and systemic acne therapies.
- Describe the approach to acne scarring.
Clinical vignettes
- A teenager presents with comedones, papules, and pustules over the face and back. Dx: Acne vulgaris.
- A middle-aged woman presents with facial flushing, erythema, and visible blood vessels, worsened by spicy food. Dx: Rosacea.
Hair & Nail Disorders
- Describe the diagnosis and management of alopecia.
- Explain the diagnosis and management of common nail disorders.
- Describe the causes of hirsutism and its evaluation.
- Explain the approach to a patient with hair loss.
- Describe fungal infections of hair and nails.
Clinical vignettes
- A young man notices patchy hair loss with well-defined smooth bald patches on the scalp. Dx: Alopecia areata.
- A patient presents with thickened, discolored, brittle nails. Dx: Onychomycosis (fungal nail infection).
Connective Tissue & Autoimmune Skin Disorders
- Describe the cutaneous features of lupus erythematosus.
- Explain the diagnosis and management of scleroderma.
- Describe the skin manifestations of dermatomyositis.
- Explain the approach to a patient with autoimmune skin disease.
- Describe the systemic associations of connective tissue skin disorders.
Clinical vignettes
- A woman presents with a photosensitive facial rash, joint pain, and oral ulcers. Dx: Cutaneous lupus erythematosus (with SLE association).
- A patient presents with tight, thickened skin of the face and hands with Raynaud's phenomenon. Dx: Systemic sclerosis (scleroderma).
Cutaneous Tumors
- Describe the diagnosis and management of benign skin tumors.
- Explain the diagnosis and management of basal and squamous cell carcinoma.
- Describe the diagnosis and management of malignant melanoma.
- Explain the ABCDE criteria for evaluating pigmented lesions.
- Describe the principles of skin cancer prevention.
Clinical vignettes
- A fair-skinned farmer presents with a slow-growing, pearly nodule with rolled edges and telangiectasia on the face. Dx: Basal cell carcinoma.
- A patient presents with an asymmetric, irregularly bordered, multi-colored mole that has recently changed in size. Dx: Suspected malignant melanoma.
Leprosy
- Describe the classification and clinical features of leprosy.
- Explain the diagnosis of leprosy including slit skin smear.
- Describe the multidrug therapy regimen for leprosy.
- Explain the diagnosis and management of leprosy reactions.
- Describe the prevention of disability in leprosy patients.
Clinical vignettes
- A patient presents with a single hypopigmented, anesthetic patch with a thickened peripheral nerve. Dx: Paucibacillary (tuberculoid) leprosy.
- A leprosy patient develops sudden painful nerve tenderness and worsening skin lesions during treatment. Dx: Leprosy reaction (Type 1 or Type 2).
Sexually Transmitted Infections
- Describe the syndromic approach to management of STIs.
- Explain the diagnosis and management of genital ulcers.
- Describe the diagnosis and management of urethral and vaginal discharge.
- Explain partner notification and counseling in STI management.
- Describe prevention strategies for sexually transmitted infections.
Clinical vignettes
- A patient presents with a single painless indurated genital ulcer with non-tender inguinal lymphadenopathy. Dx: Primary syphilis (chancre).
- A patient presents with multiple painful genital ulcers and tender inguinal lymphadenopathy with discharging sinuses. Dx: Chancroid.
Dermatological Therapeutics
- Describe the principles of topical drug delivery in dermatology.
- Explain the use of systemic drugs in dermatological conditions.
- Describe the indications for phototherapy.
- Explain the adverse effects of common dermatological medications.
- Describe the principles of cosmetic dermatology procedures.
Clinical vignettes
- A patient with widespread psoriasis is started on topical corticosteroids and counseled about the risks of prolonged use. Point: illustrates rational topical therapy principles.
- A patient requests treatment for post-acne scarring. Point: illustrates dermatological therapeutic/cosmetic procedure options.

Psychiatry

Psychiatric History Taking & Mental Status Examination
- Elicit a comprehensive psychiatric history.
- Perform and document a mental status examination.
- Describe the components of risk assessment in psychiatric evaluation.
- Explain the importance of collateral history in psychiatry.
- Describe the approach to building rapport with a psychiatric patient.
Clinical vignettes
- A psychiatry resident performs a mental status examination, noting the patient's appearance, mood, thought content, and insight. Point: illustrates the structured MSE approach.
- A patient is reluctant to share personal history; the interviewer uses open-ended, non-judgmental questions to build trust. Point: illustrates rapport-building technique.
Classification of Psychiatric Disorders
- Describe the major classification systems used in psychiatry (ICD, DSM).
- Explain the concept of a psychiatric diagnosis and comorbidity.
- Describe the biopsychosocial model of mental illness.
- Explain the distinction between neurotic and psychotic disorders.
- Describe the epidemiology of common psychiatric disorders.
Clinical vignettes
- A clinician uses ICD/DSM criteria to classify a patient's symptoms into a specific diagnostic category. Point: illustrates use of standardized classification systems.
- A community mental health survey estimates the prevalence of depression in a population. Point: illustrates psychiatric epidemiology.
Schizophrenia & Other Psychotic Disorders
- Describe the clinical features and diagnostic criteria of schizophrenia.
- Explain the differential diagnosis of psychotic disorders.
- Describe the pharmacological management of schizophrenia.
- Explain the psychosocial rehabilitation approach for psychotic disorders.
- Describe the prognosis and course of schizophrenia.
Clinical vignettes
- A young man presents with auditory hallucinations commenting on his actions, delusions of persecution, and social withdrawal for 8 months. Dx: Schizophrenia.
- A patient develops sudden psychotic symptoms after a major stressor, resolving within a month. Dx: Brief psychotic disorder.
Mood Disorders
- Describe the clinical features and diagnosis of major depressive disorder.
- Explain the clinical features and diagnosis of bipolar disorder.
- Describe the management of mood disorders.
- Explain the assessment of suicide risk in mood disorders.
- Describe the differential diagnosis of mood disturbances.
Clinical vignettes
- A 30-year-old presents with persistent low mood, anhedonia, poor sleep, and guilt feelings for 3 weeks. Dx: Major depressive disorder.
- A patient presents with elevated mood, decreased need for sleep, grandiosity, and impulsive spending for a week. Dx: Manic episode (bipolar disorder).
Anxiety, Stress & Somatoform Disorders
- Describe the clinical features and management of generalized anxiety disorder.
- Explain the diagnosis and management of panic disorder.
- Describe the diagnosis and management of post-traumatic stress disorder.
- Explain the approach to somatoform and conversion disorders.
- Describe the psychological and pharmacological management of anxiety disorders.
Clinical vignettes
- A patient presents with recurrent sudden episodes of intense fear, palpitations, and a feeling of impending doom lasting minutes. Dx: Panic disorder.
- A patient presents with multiple unexplained physical complaints over years despite negative investigations, causing significant distress. Dx: Somatic symptom disorder.
Substance Use Disorders
- Describe the clinical features of alcohol and substance dependence.
- Explain the management of alcohol withdrawal.
- Describe the approach to detoxification and rehabilitation in substance use disorders.
- Explain the pharmacological options for relapse prevention.
- Describe the social and legal aspects of substance use disorders.
Clinical vignettes
- A chronic alcoholic presents with tremors, sweating, and hallucinations 48 hours after stopping alcohol. Dx: Alcohol withdrawal — risk of delirium tremens.
- A young adult shows tolerance, craving, and withdrawal symptoms related to opioid use. Dx: Opioid dependence syndrome.
Organic Mental Disorders & Dementia
- Describe the diagnosis and management of delirium.
- Explain the differentiation between delirium and dementia.
- Describe the diagnosis and management of common dementias.
- Explain the approach to behavioral and psychological symptoms of dementia.
- Describe caregiver support strategies in dementia management.
Clinical vignettes
- An elderly patient shows progressive memory loss, disorientation, and personality change over 2 years, with preserved consciousness. Dx: Dementia.
- A hospitalized elderly patient develops acute confusion and fluctuating attention over hours after surgery. Dx: Delirium — distinguish from dementia.
Child & Adolescent Psychiatry
- Describe the assessment of common psychiatric disorders in children.
- Explain the diagnosis and management of attention deficit hyperactivity disorder.
- Describe the diagnosis and management of autism spectrum disorder.
- Explain the approach to childhood anxiety and mood disorders.
- Describe the impact of family dynamics on child mental health.
Clinical vignettes
- A 4-year-old shows delayed speech, poor eye contact, and repetitive behaviors. Dx: Autism spectrum disorder.
- A school-age child has persistent difficulty with attention, hyperactivity, and impulsivity affecting academic performance. Dx: ADHD.
Personality Disorders
- Describe the classification of personality disorders.
- Explain the clinical features of common personality disorders.
- Describe the approach to management of personality disorders.
- Explain the challenges in the therapeutic relationship with personality disorder patients.
- Describe the differential diagnosis of personality disorders from other psychiatric conditions.
Clinical vignettes
- A young woman shows a pattern of unstable relationships, impulsivity, and recurrent self-harm since adolescence. Dx: Borderline personality disorder.
- A man shows a pervasive pattern of disregard for others' rights, deceitfulness, and lack of remorse since adolescence. Dx: Antisocial personality disorder.
Psychiatric Emergencies & Suicide Risk
- Describe the assessment and management of a suicidal patient.
- Explain the management of acute agitation and violent behavior.
- Describe the approach to a patient with acute psychosis.
- Explain the legal aspects of involuntary psychiatric admission.
- Describe crisis intervention strategies in psychiatric emergencies.
Clinical vignettes
- A patient with severe depression expresses a specific plan and intent to end their life. Point: illustrates urgent suicide risk assessment and safety planning.
- An agitated patient with psychosis becomes aggressive and poses a risk to staff on the ward. Point: illustrates management of acute behavioral emergency.
Psychopharmacology
- Describe the classification and mechanism of action of antipsychotics.
- Explain the classification and mechanism of action of antidepressants.
- Describe the use and monitoring of mood stabilizers.
- Explain the adverse effects of common psychotropic medications.
- Describe the principles of medication adherence in psychiatric treatment.
Clinical vignettes
- A patient on antipsychotics develops muscle rigidity, high fever, and altered consciousness. Dx: Neuroleptic malignant syndrome.
- A patient started on an SSRI reports nausea and restlessness in the first week. Point: illustrates common early side effects requiring counseling for adherence.
Psychotherapy & Community Psychiatry
- Describe the basic principles of common psychotherapeutic approaches.
- Explain the role of community-based mental health services.
- Describe the stigma associated with mental illness and strategies to reduce it.
- Explain the principles of rehabilitation for chronic mental illness.
- Describe national mental health programmes and policies.
Clinical vignettes
- A patient with mild depression is offered cognitive behavioral therapy as first-line treatment. Point: illustrates non-pharmacological management.
- A district hospital integrates mental health services into primary care under the National Mental Health Programme. Point: illustrates community psychiatry delivery.

Radiodiagnosis

Basic Physics of Radiology & Radiation Safety
- Describe the basic physics of X-ray production.
- Explain the principles of radiation protection and safety.
- Describe the biological effects of ionizing radiation.
- Explain the ALARA principle in radiological practice.
- Describe the regulatory framework for radiation safety.
Clinical vignettes
- A pregnant technician follows lead-apron shielding protocols while assisting an X-ray procedure. Point: illustrates radiation protection principles (ALARA).
- A radiology department maintains dose records for staff using film badges. Point: illustrates occupational radiation safety monitoring.
Imaging Modalities — X-ray, CT, MRI, USG
- Describe the principles of plain radiography.
- Explain the basic principles of computed tomography.
- Describe the principles of magnetic resonance imaging.
- Explain the principles of ultrasonography.
- Describe the indications and limitations of each imaging modality.
Clinical vignettes
- A patient with suspected stroke undergoes a non-contrast CT scan as first-line imaging. Point: illustrates appropriate modality selection for acute stroke.
- A pregnant woman with suspected gallstones is imaged with ultrasound rather than CT to avoid radiation exposure. Point: illustrates modality choice based on safety.
Chest Imaging
- Describe the systematic approach to reading a chest X-ray.
- Explain the radiological features of common lung diseases.
- Describe the imaging findings in pulmonary tuberculosis.
- Explain the role of CT chest in evaluating lung pathology.
- Describe the imaging approach to mediastinal masses.
Clinical vignettes
- A patient with chronic cough and hemoptysis has a chest X-ray showing a cavitary upper lobe lesion. Dx: Suspected pulmonary tuberculosis.
- A young adult presents with a widened mediastinum on chest X-ray and is further evaluated with CT. Point: illustrates the imaging approach to a mediastinal mass.
Gastrointestinal Imaging
- Describe the imaging approach to intestinal obstruction.
- Explain the role of contrast studies in GI imaging.
- Describe the imaging findings in common GI pathologies.
- Explain the role of CT and ultrasound in acute abdomen evaluation.
- Describe the imaging approach to GI malignancies.
Clinical vignettes
- A patient with dysphagia undergoes a barium swallow showing an irregular filling defect in the esophagus. Dx: Suspected esophageal carcinoma.
- A patient with suspected bowel obstruction has an erect abdominal X-ray showing multiple air-fluid levels. Point: illustrates a radiological sign of intestinal obstruction.
Hepatobiliary & Pancreatic Imaging
- Describe the ultrasound findings in gallstone disease.
- Explain the imaging approach to obstructive jaundice.
- Describe the imaging findings in liver masses.
- Explain the role of imaging in pancreatitis evaluation.
- Describe the imaging approach to hepatobiliary malignancies.
Clinical vignettes
- A patient with right upper quadrant pain has an ultrasound showing echogenic foci with acoustic shadowing in the gallbladder. Dx: Gallstones (cholelithiasis).
- A patient with painless jaundice has imaging showing a dilated common bile duct and a pancreatic head mass. Dx: Suspected carcinoma head of pancreas.
Genitourinary Imaging
- Describe the imaging approach to urinary tract calculi.
- Explain the role of ultrasound in renal disease evaluation.
- Describe the imaging findings in urinary tract obstruction.
- Explain the imaging approach to renal and bladder masses.
- Describe the role of imaging in male and female pelvic pathology.
Clinical vignettes
- A patient with loin pain and hematuria undergoes a non-contrast CT KUB showing a calculus at the ureterovesical junction. Dx: Ureteric calculus.
- A woman with pelvic pain undergoes ultrasound showing a complex adnexal mass. Point: illustrates gynecological imaging workup.
Musculoskeletal Imaging
- Describe the systematic approach to reading a skeletal X-ray.
- Explain the imaging findings in common fractures.
- Describe the imaging approach to bone and joint infections.
- Explain the role of MRI in musculoskeletal soft tissue evaluation.
- Describe the imaging findings in metabolic bone disease.
Clinical vignettes
- An X-ray of a trauma patient's wrist shows a distal radius fracture with dorsal angulation. Dx: Colles' fracture.
- An MRI of the knee in an athlete with instability shows discontinuity of the anterior cruciate ligament. Dx: ACL tear.
Neuroimaging
- Describe the imaging approach to stroke.
- Explain the imaging findings in traumatic brain injury.
- Describe the imaging approach to intracranial mass lesions.
- Explain the role of CT and MRI in evaluating headache.
- Describe the imaging findings in common spinal disorders.
Clinical vignettes
- A patient with acute severe headache and neck stiffness has a CT scan showing blood in the basal cisterns. Dx: Subarachnoid hemorrhage.
- A patient with sciatica has an MRI lumbar spine showing a herniated disc compressing the nerve root. Dx: Prolapsed intervertebral disc.
Obstetric & Gynecological Imaging
- Describe the role of ultrasound in confirming and dating pregnancy.
- Explain the use of ultrasound in fetal anomaly screening.
- Describe the imaging approach to common gynecological conditions.
- Explain the role of Doppler studies in obstetric imaging.
- Describe the imaging findings in ectopic pregnancy.
Clinical vignettes
- A pregnant woman at 20 weeks undergoes a routine anomaly scan to assess fetal structural development. Point: illustrates standard obstetric ultrasound use.
- A woman with a positive pregnancy test and lower abdominal pain has ultrasound showing an empty uterus with an adnexal mass. Dx: Suspected ectopic pregnancy.
Cardiovascular Imaging
- Describe the radiological features of common cardiac conditions on chest X-ray.
- Explain the role of echocardiography in cardiac evaluation.
- Describe the imaging approach to peripheral vascular disease.
- Explain the role of CT angiography in vascular imaging.
- Describe the imaging findings in congenital heart disease.
Clinical vignettes
- A patient with chest pain undergoes CT coronary angiography showing significant stenosis of the left anterior descending artery. Point: illustrates cardiovascular imaging for coronary artery disease.
- An infant with cyanosis undergoes echocardiography confirming a structural cardiac defect. Point: illustrates imaging diagnosis of congenital heart disease.
Interventional Radiology — Basics
- Describe the basic principles of image-guided procedures.
- Explain the indications for common interventional radiology procedures.
- Describe the role of image-guided biopsy.
- Explain the basic principles of vascular intervention.
- Describe the precautions taken during interventional procedures.
Clinical vignettes
- A patient with liver cancer undergoes image-guided transarterial chemoembolization. Point: illustrates minimally invasive interventional radiology treatment.
- A patient with a suspicious lung mass undergoes CT-guided percutaneous biopsy for tissue diagnosis. Point: illustrates an interventional diagnostic procedure.
Contrast Media & Radiation Hazards
- Describe the types and use of contrast media in imaging.
- Explain the recognition and management of contrast reactions.
- Describe the precautions for contrast use in renal impairment.
- Explain the hazards of radiation exposure in pregnancy.
- Describe strategies to minimize radiation dose in imaging.
Clinical vignettes
- A patient develops sudden breathlessness, hypotension, and urticaria shortly after IV contrast injection for a CT scan. Dx: Contrast-induced anaphylactoid reaction.
- A patient with pre-existing renal impairment undergoes a hydration protocol before contrast-enhanced CT. Point: illustrates prevention of contrast-induced nephropathy.

Anaesthesiology

Preoperative Assessment & Optimization
- Describe the components of preoperative anesthetic assessment.
- Explain the ASA physical status classification.
- Describe the optimization of comorbid conditions before surgery.
- Explain the principles of preoperative fasting guidelines.
- Describe informed consent for anesthesia.
Clinical vignettes
- A patient scheduled for elective surgery undergoes preoperative assessment and is classified as ASA Grade II due to controlled hypertension. Point: illustrates preoperative risk stratification.
- A patient with poorly controlled diabetes is optimized with insulin before elective surgery. Point: illustrates preoperative medical optimization.
General Anesthesia — Principles & Agents
- Describe the stages and mechanisms of general anesthesia.
- Explain the pharmacology of common inhalational and intravenous anesthetic agents.
- Describe the use of muscle relaxants in general anesthesia.
- Explain the balanced anesthesia technique.
- Describe the recovery phase after general anesthesia.
Clinical vignettes
- A patient is induced with intravenous propofol followed by maintenance with an inhalational agent for surgery. Point: illustrates standard general anesthesia technique.
- A patient develops high fever, muscle rigidity, and rapidly rising end-tidal CO2 shortly after induction of general anesthesia. Dx: Malignant hyperthermia.
Airway Management
- Describe the assessment of a difficult airway.
- Explain the techniques of basic and advanced airway management.
- Describe the indications and technique of endotracheal intubation.
- Explain the management of a failed airway.
- Describe the use of supraglottic airway devices.
Clinical vignettes
- An anesthesiologist encounters an unexpectedly difficult intubation with poor visualization of the vocal cords. Point: illustrates the difficult airway management algorithm.
- A patient undergoing a short day-care procedure is managed with a laryngeal mask airway instead of endotracheal intubation. Point: illustrates supraglottic airway use.
Regional & Local Anesthesia
- Describe the pharmacology of local anesthetic agents.
- Explain the technique of spinal and epidural anesthesia.
- Describe the complications of regional anesthesia.
- Explain the indications for peripheral nerve blocks.
- Describe the management of local anesthetic systemic toxicity.
Clinical vignettes
- A patient undergoing lower limb surgery receives spinal anesthesia with loss of sensation below the umbilicus. Point: illustrates spinal anesthesia technique.
- A patient develops perioral numbness, tinnitus, and seizures during a peripheral nerve block. Dx: Local anesthetic systemic toxicity.
Monitoring During Anesthesia
- Describe the standard monitoring parameters during anesthesia.
- Explain the principles of pulse oximetry and capnography.
- Describe the monitoring of neuromuscular blockade.
- Explain the use of invasive hemodynamic monitoring.
- Describe the depth of anesthesia monitoring techniques.
Clinical vignettes
- During surgery, the pulse oximeter shows a sudden drop in oxygen saturation, prompting immediate airway and ventilation checks. Point: illustrates intraoperative monitoring response.
- A patient's end-tidal CO2 monitor shows a sudden fall to near zero during surgery. Dx: Possible esophageal intubation or cardiac arrest — needs immediate evaluation.
Fluid & Blood Transfusion Management
- Describe the principles of perioperative fluid therapy.
- Explain the assessment and management of intraoperative blood loss.
- Describe the indications for blood component transfusion.
- Explain the recognition and management of transfusion reactions.
- Describe the principles of massive transfusion protocols.
Clinical vignettes
- A trauma patient with ongoing hemorrhage requires activation of the massive transfusion protocol. Point: illustrates coordinated blood product replacement in major bleeding.
- A surgical patient develops fever and chills shortly after starting a blood transfusion. Dx: Transfusion reaction — stop transfusion and investigate.
Cardiopulmonary Resuscitation
- Perform basic and advanced cardiac life support.
- Describe the algorithm for management of cardiac arrest.
- Explain the pharmacology of drugs used in resuscitation.
- Describe post-resuscitation care.
- Explain the ethical considerations in resuscitation decisions.
Clinical vignettes
- A patient in the operating room suddenly loses pulse; the team initiates chest compressions and follows the ACLS algorithm. Point: illustrates the CPR/ACLS protocol.
- A family requests withholding resuscitation for a terminally ill relative. Point: illustrates ethical considerations around do-not-resuscitate decisions.
Postoperative Care & Pain Management
- Describe the components of postoperative recovery room care.
- Explain the assessment and management of postoperative pain.
- Describe the use of multimodal analgesia.
- Explain the recognition and management of postoperative complications.
- Describe the principles of patient-controlled analgesia.
Clinical vignettes
- A patient recovering from major abdominal surgery has poorly controlled pain despite scheduled analgesics. Point: illustrates escalation to patient-controlled analgesia.
- A postoperative patient develops nausea, vomiting, and drowsiness after opioid analgesia. Point: illustrates recognition and management of opioid side effects.
Anesthesia for Special Situations (Obstetric, Pediatric)
- Describe the physiological changes relevant to obstetric anesthesia.
- Explain the anesthetic management for cesarean section.
- Describe the considerations for pediatric anesthesia.
- Explain the anesthetic management in the elderly and comorbid patients.
- Describe anesthesia considerations for emergency surgery.
Clinical vignettes
- A pregnant woman requiring emergency cesarean section is given spinal anesthesia with left lateral tilt to avoid aortocaval compression. Point: illustrates obstetric anesthesia considerations.
- A child undergoing a short procedure is induced with inhalational anesthesia due to difficult IV access. Point: illustrates pediatric anesthesia technique.
Critical Care & Ventilator Management
- Describe the indications for mechanical ventilation.
- Explain the basic modes of mechanical ventilation.
- Describe the management of a patient in the intensive care unit.
- Explain the principles of weaning from mechanical ventilation.
- Describe the recognition and management of ventilator-associated complications.
Clinical vignettes
- A patient with severe pneumonia and worsening hypoxia is intubated and started on mechanical ventilation. Point: illustrates indication for ventilatory support.
- A ventilated ICU patient develops new fever and purulent secretions after 5 days on the ventilator. Dx: Ventilator-associated pneumonia.
Anesthetic Complications & Emergencies
- Describe the recognition and management of anaphylaxis under anesthesia.
- Explain the management of malignant hyperthermia.
- Describe the recognition and management of aspiration during anesthesia.
- Explain the approach to intraoperative hypotension and hypoxia.
- Describe the management of awareness under anesthesia.
Clinical vignettes
- A patient recalls conversations during surgery despite being under general anesthesia. Dx: Intraoperative awareness — a recognized anesthetic complication.
- A patient develops sudden bronchospasm and desaturation shortly after intubation. Dx: Laryngospasm/bronchospasm — anesthetic emergency.
Chronic Pain Medicine
- Describe the classification and mechanisms of chronic pain.
- Explain the pharmacological management of chronic pain.
- Describe the role of interventional techniques in chronic pain management.
- Explain the multidisciplinary approach to chronic pain management.
- Describe the management of cancer-related chronic pain.
Clinical vignettes
- A patient with diabetic neuropathy reports persistent burning pain in both feet despite standard analgesics. Point: illustrates a neuropathic pain management approach.
- A terminal cancer patient's pain is managed by stepping up the WHO analgesic ladder to strong opioids. Point: illustrates cancer pain management principles.

Residency chapters

Chapter-level breakdown for each residency subject — use these as the unit of mapping when building competencies above.

Internal Medicine Residency

Acute Coronary Syndromes
- Direct primary PCI and fibrinolytic decision-making in STEMI.
- Manage NSTEMI and unstable angina using risk-stratified antithrombotic therapy.
- Manage cardiogenic shock complicating acute myocardial infarction.
- Diagnose and manage mechanical complications of MI (papillary muscle rupture, VSD, free wall rupture).
- Direct secondary prevention pharmacotherapy after acute coronary syndrome.
Clinical vignettes
- A 58-year-old man presents with crushing central chest pain for 45 minutes; ECG shows ST elevation in V1–V4. Dx: Anterior STEMI — activate primary PCI pathway, target door-to-balloon <90 min.
- Three days after an inferior MI a patient develops sudden hypotension and a new pansystolic murmur with pulmonary oedema. Dx: Papillary muscle rupture causing acute mitral regurgitation — needs emergency surgery.
Heart Failure & Cardiomyopathy
- Manage acute decompensated heart failure with reduced and preserved ejection fraction.
- Direct guideline-directed medical therapy titration in chronic heart failure.
- Manage dilated, hypertrophic, and restrictive cardiomyopathy.
- Direct inotropic and mechanical circulatory support in cardiogenic shock.
- Manage cardiorenal syndrome in advanced heart failure.
Clinical vignettes
- A patient with known HFrEF on optimal GDMT is admitted with worsening dyspnoea; after diuretic uptitration the creatinine rises sharply. Dx: Type 1 cardiorenal syndrome — balance decongestion against renal perfusion.
- A previously well woman develops severe breathlessness and reduced ejection fraction two weeks after delivery. Dx: Peripartum cardiomyopathy.
Arrhythmias & Syncope
- Manage atrial fibrillation including rate/rhythm control and anticoagulation decisions.
- Diagnose and manage ventricular tachycardia and sudden cardiac death risk.
- Manage bradyarrhythmias requiring temporary or permanent pacing.
- Direct the work-up of unexplained syncope.
- Interpret indications for implantable cardioverter-defibrillator therapy.
Clinical vignettes
- A 70-year-old with palpitations has an irregularly irregular pulse and a CHA₂DS₂-VASc score of 4. Point: rate/rhythm control plus anticoagulation decision-making in atrial fibrillation.
- A young athlete has recurrent exertional syncope, a family history of sudden death, and QTc 480 ms. Dx: Long QT syndrome — risk of torsades de pointes; restrict competitive sport pending evaluation.
Valvular Disease, Endocarditis & Pericardial Disease
- Manage severe aortic stenosis and mitral regurgitation including intervention timing.
- Diagnose and manage infective endocarditis including embolic and valvular complications.
- Manage acute and constrictive pericarditis and cardiac tamponade.
- Direct anticoagulation management in prosthetic heart valves.
- Manage rheumatic heart disease complications in adults.
Clinical vignettes
- An intravenous drug user presents with fever, a new murmur, and septic pulmonary emboli on chest X-ray. Dx: Tricuspid valve infective endocarditis.
- A patient develops pleuritic chest pain relieved by leaning forward with diffuse concave ST elevation on ECG, days after a viral illness. Dx: Acute pericarditis — watch for pulsus paradoxus signalling tamponade.
Airways Disease — Asthma & COPD
- Manage status asthmaticus requiring escalation to non-invasive or invasive ventilation.
- Direct step-up biologic therapy in severe eosinophilic asthma.
- Manage acute COPD exacerbation with respiratory acidosis.
- Direct long-term oxygen and pulmonary rehabilitation therapy in COPD.
- Manage bronchiectasis and its infective exacerbations.
Clinical vignettes
- A young asthmatic arrives unable to complete sentences, with a silent chest and PEFR <33% predicted. Dx: Life-threatening acute severe asthma — needs continuous nebulisation, IV steroids, senior/ICU input.
- A known COPD patient has worsening dyspnoea, purulent sputum, and arterial pH 7.28 with hypercapnia. Point: non-invasive ventilation is indicated for acute hypercapnic respiratory failure not responding to initial therapy.
Interstitial Lung Disease & Pulmonary Vascular Disease
- Direct the diagnostic work-up of idiopathic pulmonary fibrosis and other ILDs.
- Manage acute and chronic pulmonary embolism including thrombolysis decisions.
- Diagnose and manage pulmonary arterial hypertension.
- Manage hypersensitivity pneumonitis and connective-tissue-associated ILD.
- Direct long-term antifibrotic therapy in progressive fibrosing ILD.
Clinical vignettes
- A 65-year-old man has progressive exertional dyspnoea, bibasal Velcro-like crackles, and HRCT showing honeycombing. Dx: Idiopathic pulmonary fibrosis.
- A post-operative patient develops sudden pleuritic chest pain, tachycardia, and hypoxia with a raised D-dimer. Dx: Acute pulmonary embolism — risk-stratify for thrombolysis versus anticoagulation alone.
Critical Respiratory Failure & Pleural Disease
- Direct lung-protective ventilation in ARDS.
- Manage massive pleural effusion and empyema.
- Manage tension and spontaneous pneumothorax.
- Direct weaning strategies from prolonged mechanical ventilation.
- Manage acute exacerbation of chronic respiratory failure requiring NIV.
Clinical vignettes
- A trauma patient develops sudden hypotension, distended neck veins, tracheal deviation, and absent breath sounds on one side. Dx: Tension pneumothorax — immediate needle decompression, do not wait for imaging.
- A septic patient has bilateral infiltrates and a PaO₂/FiO₂ ratio <100 despite high inspired oxygen. Dx: Severe ARDS — institute lung-protective low tidal volume ventilation.
Acute & Chronic Kidney Disease
- Direct the diagnostic work-up and staging of acute kidney injury by etiology.
- Manage rapidly progressive glomerulonephritis.
- Direct long-term CKD management including anemia and mineral bone disease.
- Manage contrast-induced and drug-induced nephrotoxicity.
- Direct the timing and modality selection for renal replacement therapy.
Clinical vignettes
- A patient's creatinine rises 48 hours after an iodinated contrast CT, with oliguria. Dx: Contrast-induced nephropathy.
- A patient presents with haemoptysis, haematuria, and rapidly rising creatinine; anti-GBM antibodies are positive. Dx: Anti-GBM disease (Goodpasture syndrome) causing rapidly progressive glomerulonephritis.
Glomerular Disease & Renal Transplant Medicine
- Manage nephrotic syndrome from membranous nephropathy and FSGS.
- Manage IgA nephropathy and lupus nephritis.
- Direct immunosuppression protocols in renal transplant recipients.
- Manage acute and chronic transplant rejection.
- Manage electrolyte disorders specific to transplant immunosuppression.
Clinical vignettes
- A patient has nephrotic-range proteinuria with normal complement levels; biopsy shows segmental sclerosis. Dx: Focal segmental glomerulosclerosis (FSGS).
- A renal transplant recipient develops fever and a rising creatinine; biopsy shows interstitial tubulitis. Dx: Acute T-cell mediated (cellular) rejection.
Upper & Lower GI Bleeding, Liver Failure
- Direct endoscopic and pharmacologic management of variceal hemorrhage.
- Manage non-variceal upper GI bleeding including peptic ulcer disease.
- Manage acute liver failure and hepatic encephalopathy.
- Direct the management of decompensated cirrhosis and hepatorenal syndrome.
- Manage spontaneous bacterial peritonitis.
Clinical vignettes
- A known cirrhotic presents with haematemesis and hypotension. Point: resuscitate, start octreotide and prophylactic antibiotics, arrange urgent endoscopy for suspected variceal bleed.
- A cirrhotic patient becomes acutely confused with asterixis and an elevated ammonia after a GI bleed. Dx: Hepatic encephalopathy precipitated by GI bleeding.
Inflammatory Bowel Disease & Pancreatico-biliary Disease
- Direct step-up biologic therapy in ulcerative colitis and Crohn's disease.
- Manage acute severe ulcerative colitis requiring rescue therapy.
- Manage severe acute pancreatitis and its local complications.
- Diagnose and manage ascending cholangitis.
- Manage chronic pancreatitis and pancreatic exocrine insufficiency.
Clinical vignettes
- A patient with ulcerative colitis has >6 bloody stools a day, fever, tachycardia, and colonic dilation on abdominal X-ray. Dx: Acute severe ulcerative colitis with risk of toxic megacolon — needs IV steroids and surgical review.
- A patient with epigastric pain radiating to the back has markedly elevated lipase and high Ranson/APACHE criteria. Dx: Severe acute pancreatitis — aggressive fluid resuscitation and monitoring for necrosis.
Diabetes Mellitus & Acute Metabolic Emergencies
- Manage diabetic ketoacidosis and hyperosmolar hyperglycemic state.
- Direct insulin regimen individualization in complicated type 1 and type 2 diabetes.
- Manage diabetic nephropathy, retinopathy, and neuropathy in the inpatient setting.
- Manage severe hypoglycemia and its precipitants.
- Direct perioperative glycemic management.
Clinical vignettes
- A type 1 diabetic presents with vomiting, Kussmaul breathing, glucose 450 mg/dL, and ketonuria. Dx: Diabetic ketoacidosis — fluids, fixed-rate insulin infusion, potassium replacement.
- An elderly type 2 diabetic has glucose 900 mg/dL without significant ketosis, altered sensorium, and markedly raised osmolality. Dx: Hyperosmolar hyperglycaemic state.
Thyroid, Adrenal & Pituitary Disorders
- Manage thyroid storm and myxedema coma.
- Diagnose and manage adrenal insufficiency and adrenal crisis.
- Manage Cushing syndrome and its subtypes.
- Diagnose and manage pituitary apoplexy and hypopituitarism.
- Manage disorders of calcium and parathyroid function.
Clinical vignettes
- A patient develops fever, tachycardia, and agitation after surgery in the setting of untreated hyperthyroidism. Dx: Thyroid storm — beta-blockade, antithyroid drugs, iodine, steroids.
- A patient with known adrenal insufficiency misses their steroid doses during a febrile illness and presents with hypotension, hyponatraemia, and hyperkalaemia. Dx: Adrenal (Addisonian) crisis — immediate IV hydrocortisone.
Sepsis, Multidrug-Resistant & Opportunistic Infections
- Direct source control and antimicrobial escalation in septic shock.
- Manage carbapenem-resistant and other multidrug-resistant Gram-negative infections.
- Manage invasive fungal infections in the immunocompromised host.
- Diagnose and manage tuberculosis including drug-resistant forms.
- Manage HIV-associated opportunistic infections including PJP and cryptococcal meningitis.
Clinical vignettes
- An ICU patient with a prolonged stay grows an isolate resistant to carbapenems. Point: carbapenem-resistant Enterobacteriaceae require combination therapy and strict infection control.
- A patient with HIV and CD4 count <100 presents with dyspnoea and bilateral ground-glass opacities on CT. Dx: Pneumocystis jirovecii pneumonia.
Rheumatologic Emergencies & Vasculitis
- Manage ANCA-associated vasculitis with organ-threatening disease.
- Manage catastrophic antiphospholipid syndrome and lupus flares.
- Diagnose and manage giant cell arteritis and Takayasu arteritis.
- Manage acute gout and septic arthritis.
- Direct biologic and DMARD therapy in refractory rheumatoid arthritis.
Clinical vignettes
- A patient with chronic sinusitis develops haemoptysis and renal failure with a positive c-ANCA. Dx: Granulomatosis with polyangiitis (GPA).
- An elderly patient has new headache, jaw claudication, and a tender temporal artery with ESR 100. Dx: Giant cell arteritis — start high-dose steroids immediately to prevent irreversible vision loss.
Hematological Malignancy & Bleeding Disorders
- Direct the diagnostic work-up and induction management of acute leukemia.
- Manage tumor lysis syndrome and febrile neutropenia.
- Manage disseminated intravascular coagulation and thrombotic microangiopathy.
- Manage complications of hematopoietic stem cell transplantation.
- Direct anticoagulation management in complex thrombotic disorders.
Clinical vignettes
- A patient presents with fatigue and bruising; peripheral smear shows blasts with Auer rods. Dx: Acute myeloid leukaemia.
- A septic patient bleeds from IV sites with low platelets, prolonged PT/aPTT, and low fibrinogen. Dx: Disseminated intravascular coagulation.
Stroke, Status Epilepticus & Neurocritical Care
- Direct thrombolysis and thrombectomy decision-making in acute ischemic stroke.
- Manage intracerebral and subarachnoid hemorrhage.
- Manage refractory and super-refractory status epilepticus.
- Manage raised intracranial pressure and herniation syndromes.
- Diagnose and manage Guillain-Barré syndrome and myasthenic crisis.
Clinical vignettes
- A patient develops sudden right-sided weakness and aphasia two hours ago; CT shows no haemorrhage. Point: thrombolysis eligibility must be assessed rapidly within the therapeutic window.
- A patient continues seizing for over 30 minutes despite two anti-epileptic drugs. Dx: Refractory status epilepticus — requires anaesthetic infusion and intubation.
Encephalitis, Meningitis & CNS Infections
- Direct empiric and targeted therapy in bacterial meningitis.
- Manage viral and autoimmune encephalitis.
- Manage tuberculous and cryptococcal meningitis.
- Diagnose and manage brain abscess.
- Manage neurological complications of HIV infection.
Clinical vignettes
- A patient presents with fever, neck stiffness, photophobia, and a non-blanching petechial rash. Dx: Meningococcal meningitis — give antibiotics immediately, do not delay for imaging or LP.
- A patient develops fever with behavioural change; MRI shows temporal lobe changes and CSF PCR is positive. Dx: Herpes simplex encephalitis — start IV aciclovir empirically while awaiting confirmation.
Septic Shock & Multi-organ Dysfunction
- Direct hemodynamic resuscitation and vasopressor selection in septic shock.
- Manage acute respiratory distress syndrome complicating sepsis.
- Manage disseminated intravascular coagulation in critical illness.
- Direct sedation and delirium management in the ICU.
- Lead goals-of-care discussions in irreversible multi-organ failure.
Clinical vignettes
- A patient remains hypotensive despite adequate fluid resuscitation with a lactate of 4 mmol/L. Point: norepinephrine is first-line vasopressor; identify and control the septic source early.
- A patient with irreversible multi-organ failure is discussed at a family meeting. Point: shared decision-making and goals-of-care conversations are essential in irreversible critical illness.
Poisoning, Envenomation & Toxidromes
- Manage severe organophosphate and paracetamol poisoning.
- Manage tricyclic antidepressant and other cardiotoxic overdoses.
- Direct antivenom therapy in severe snake envenomation.
- Manage alcohol withdrawal and Wernicke's encephalopathy.
- Direct extracorporeal removal techniques in severe poisoning.
Clinical vignettes
- A farmer presents with miosis, salivation, bradycardia, and fasciculations after pesticide exposure. Dx: Organophosphate poisoning — atropine and pralidoxime.
- A snake-bite victim develops bleeding gums and a non-clotting 20-minute whole blood clotting test. Dx: Viper envenomation with coagulopathy — requires antivenom.
Medical Education, Research & Quality Improvement
- Design and deliver bedside teaching for undergraduate and junior trainees.
- Critically appraise clinical literature relevant to internal medicine practice.
- Lead a quality improvement or morbidity-mortality review project.
- Apply principles of evidence-based medicine to complex clinical decisions.
- Demonstrate competence in scholarly writing and case-based reporting.
Clinical vignettes
- A resident notices recurring medication errors on the ward. Point: a structured root-cause analysis should guide the design of a quality improvement project.
- A junior doctor is asked to teach bedside clinical examination to medical students. Point: structured feedback frameworks (e.g., Pendleton's rules) improve the effectiveness of clinical teaching.

Family Medicine Residency

Principles of Family Medicine & Continuity of Care
- Apply the biopsychosocial model to patient-centered care.
- Demonstrate longitudinal continuity of care across the patient lifecycle.
- Coordinate care across multiple specialists and care settings for a single patient.
- Apply family systems theory to patient management.
- Manage care transitions between hospital, specialist, and primary care.
Clinical vignettes
- A patient followed for ten years for multiple chronic problems presents with vague new fatigue. Point: continuity of care allows subtle deviation from a known baseline to be recognised early.
- A father's job loss is followed by stress-related symptoms across several family members. Point: a family-centred approach addresses the social context, not only the presenting symptom.
Hypertension & Diabetes in Primary Care
- Direct stepwise antihypertensive therapy including resistant hypertension.
- Manage type 2 diabetes with insulin initiation and intensification in primary care.
- Screen for and manage diabetic and hypertensive end-organ damage.
- Manage metabolic syndrome and dyslipidemia in primary care.
- Apply structured chronic disease review protocols for cardiometabolic risk.
Clinical vignettes
- A patient's blood pressure remains 160/100 despite three antihypertensive agents at adequate doses. Point: work up resistant hypertension — check adherence, technique, and secondary causes.
- A patient with type 2 diabetes has HbA1c 9% and repeatedly misses follow-up visits. Point: stepwise therapy intensification alongside addressing barriers to adherence.
Chronic Respiratory & Cardiac Disease in Primary Care
- Manage stable asthma and COPD in the outpatient setting including inhaler technique.
- Manage stable heart failure and atrial fibrillation in primary care.
- Direct long-term anticoagulation monitoring in primary care.
- Coordinate specialist referral for uncontrolled chronic cardiopulmonary disease.
- Manage smoking cessation as part of chronic disease management.
Clinical vignettes
- A known COPD patient reports increasing breathlessness and sputum purulence without red-flag features. Point: outpatient exacerbation management with a short steroid course and antibiotics if indicated.
- A stable heart failure patient reports 2 kg weight gain over one week. Point: early recognition and diuretic adjustment in clinic can prevent hospital admission.
Musculoskeletal & Chronic Pain in Primary Care
- Manage osteoarthritis and mechanical low back pain in primary care.
- Direct chronic non-cancer pain management including opioid stewardship.
- Manage common soft-tissue injuries and overuse syndromes.
- Diagnose and initially manage inflammatory arthritis in primary care.
- Direct osteoporosis screening and fracture prevention.
Clinical vignettes
- A 50-year-old with chronic low back pain and no red-flag features requests an MRI. Point: reassurance and encouraging activity are preferred over early imaging in non-specific low back pain.
- An elderly patient on long-term NSAIDs for osteoarthritis develops epigastric pain. Point: reassess the analgesic ladder and add gastroprotection.
Undifferentiated Illness & Diagnostic Reasoning
- Apply a structured approach to the undifferentiated presenting complaint.
- Use pre-test probability to guide investigation in primary care.
- Recognize red-flag symptoms warranting urgent referral in common presentations (chest pain, headache, abdominal pain).
- Manage diagnostic uncertainty in the outpatient setting.
- Apply cost-effective investigation strategies in resource-limited settings.
Clinical vignettes
- A young adult presents with fatigue and weight loss that do not fit a clear pattern. Point: structured follow-up and safety-netting are key in managing undifferentiated presentations.
- A patient has recurrent non-specific abdominal pain despite normal prior work-up. Point: a biopsychosocial approach avoids unnecessary repeat investigation.
Preventive Medicine & Screening
- Apply age- and risk-appropriate cancer screening guidelines.
- Direct immunization schedules across the lifespan including adult catch-up vaccination.
- Counsel patients on lifestyle modification for cardiovascular risk reduction.
- Apply cardiovascular risk stratification tools in periodic health examination.
- Design a practice-level preventive care recall system.
Clinical vignettes
- A 50-year-old is due for colorectal cancer screening but is hesitant. Point: shared decision-making across available screening modalities improves uptake.
- A long-term smoker asks for help quitting. Point: brief intervention combined with pharmacotherapy improves cessation rates.
Antenatal Care & Obstetric Complications in Primary Care
- Provide antenatal care and identify indications for specialist referral.
- Manage gestational diabetes and hypertensive disorders of pregnancy in shared care.
- Recognize and initially manage obstetric emergencies (postpartum hemorrhage, eclampsia).
- Provide postpartum care including screening for postpartum depression.
- Provide family planning and contraceptive counseling across methods.
Clinical vignettes
- A pregnant woman at 32 weeks has blood pressure 150/95 with new proteinuria. Dx: Pre-eclampsia — refer urgently for obstetric assessment.
- A routine antenatal glucose challenge test returns abnormal. Dx: Gestational diabetes — dietary counselling and glucose monitoring.
Child Health in Family Practice
- Manage well-child visits including growth and developmental surveillance.
- Manage common childhood infections and febrile illness in the outpatient setting.
- Recognize and initially manage pediatric emergencies in primary care.
- Direct childhood immunization and catch-up scheduling.
- Screen for developmental delay and refer appropriately.
Clinical vignettes
- A 2-year-old presents with fever and repeated ear pulling. Dx: Acute otitis media.
- A 9-month-old is not meeting expected developmental milestones. Point: early referral for formal developmental assessment.
Geriatric Care in Family Practice
- Perform a comprehensive functional assessment of the older adult in primary care.
- Manage polypharmacy and deprescribing in elderly patients.
- Manage falls risk, frailty, and cognitive decline in the outpatient setting.
- Coordinate home-based and community care for frail elderly patients.
- Support family caregivers of elderly or chronically ill patients.
Clinical vignettes
- An 80-year-old on multiple medications has a recent unexplained fall. Point: medication review for polypharmacy as a modifiable falls risk.
- An elderly patient living alone shows declining self-care. Point: home assessment and referral to community support services.
Mental Health & Substance Use in Primary Care
- Screen for and manage depression and generalized anxiety disorder in primary care.
- Apply brief intervention techniques for hazardous alcohol and substance use.
- Recognize and initially manage acute psychiatric crises including suicidality.
- Manage psychosomatic and somatoform presentations.
- Support patients and families through grief and loss.
Clinical vignettes
- A patient reports low mood and anhedonia for several weeks with a high PHQ-9 score. Dx: Major depressive episode — initiate treatment or refer as appropriate.
- A patient asks for help reducing alcohol intake. Point: brief motivational interviewing and validated screening tools (e.g., AUDIT) guide primary-care management.
Dermatology & Minor Surgical Procedures in Primary Care
- Diagnose and manage common dermatoses including eczema, psoriasis, and fungal infection.
- Recognize suspicious skin lesions warranting biopsy or referral.
- Perform common minor surgical procedures under local anesthesia.
- Manage wound care and suturing in the outpatient setting.
- Recognize and manage procedural complications in the outpatient setting.
Clinical vignettes
- A patient has a pigmented skin lesion with an irregular, changing border. Point: apply ABCDE criteria and refer promptly for excision biopsy if suspicious.
- A patient has a painful, infected ingrown toenail. Point: partial nail avulsion is an appropriate in-clinic minor procedure.
Community & Public Health Practice
- Apply epidemiological principles to a defined practice population.
- Design and implement a community health outreach initiative.
- Respond to public health emergencies and outbreaks within a primary care setting.
- Engage with local health systems and referral networks.
- Apply principles of health promotion at the community level.
Clinical vignettes
- Several villagers develop diarrhoeal illness within days of each other. Point: outbreak investigation and prompt reporting to health authorities.
- Immunisation coverage in a catchment area is noted to be low. Point: community health worker mobilisation can improve vaccine uptake.
Palliative & Home-Based Care
- Direct symptom management for patients receiving palliative care at home.
- Manage terminal care including pain, dyspnea, and delirium at end of life.
- Coordinate multidisciplinary home-based care for chronically ill patients.
- Communicate prognosis and goals of care with patients and families.
- Apply ethical principles to end-of-life decision-making in primary care.
Clinical vignettes
- A terminal cancer patient at home has uncontrolled pain. Point: systematic opioid titration alongside home-based palliative support.
- A family reports being overwhelmed caring for a bedridden relative. Point: respite care and psychosocial support reduce caregiver burden.
Practice Management & Health Systems
- Apply principles of clinic workflow and quality improvement.
- Apply principles of referral and health system navigation.
- Manage the business and administrative aspects of a family practice.
- Apply telemedicine principles to primary care delivery.
- Describe the role of health information systems in primary care.
Clinical vignettes
- A clinic is receiving complaints about long patient wait times. Point: process redesign (e.g., appointment triage) can improve patient flow.
- A new team member is unclear about referral pathways. Point: standard operating procedures support continuity and safe handover of care.

Geriatric Medicine Residency

Comprehensive Geriatric Assessment & Frailty
- Perform a structured comprehensive geriatric assessment across physical, cognitive, and social domains.
- Diagnose and stage frailty and sarcopenia using validated tools.
- Direct multidisciplinary team-based care planning for frail older adults.
- Apply comprehensive geriatric assessment to hospital discharge planning.
- Manage perioperative risk associated with frailty.
Clinical vignettes
- An 82-year-old presents with recent functional decline and multiple comorbidities. Point: comprehensive geriatric assessment identifies reversible contributors to decline.
- A frail elderly patient has unintentional weight loss and slow gait speed. Dx: Frailty syndrome — requires a multidomain intervention plan.
Dementia & Cognitive Disorders
- Direct the diagnostic work-up differentiating Alzheimer's, vascular, Lewy body, and frontotemporal dementia.
- Manage behavioral and psychological symptoms of dementia including agitation and psychosis.
- Direct pharmacological and non-pharmacological dementia management.
- Apply capacity assessment principles in cognitively impaired patients.
- Support family caregivers of patients with dementia.
Clinical vignettes
- A patient has gradual memory loss over several years with impaired MMSE and an otherwise normal neurological exam. Dx: Alzheimer's disease.
- A patient with vascular risk factors has stepwise cognitive decline. Dx: Vascular dementia.
Delirium
- Diagnose delirium using validated screening tools (e.g. CAM).
- Direct the work-up of underlying causes of delirium in hospitalized elders.
- Manage delirium using non-pharmacological strategies as first line.
- Apply judicious pharmacological management of severe agitation in delirium.
- Implement delirium prevention protocols in hospital settings.
Clinical vignettes
- A post-operative elderly patient develops acute confusion with fluctuating attention, worse at night. Dx: Delirium — search actively for a precipitant such as infection, medication, or urinary retention.
- An elderly patient with a urinary tract infection develops sudden agitation and disorientation. Point: treat the underlying cause first; avoid sedatives as first-line management.
Falls, Gait Disorders & Osteoporosis
- Direct multifactorial falls risk assessment in older adults.
- Manage gait and balance disorders including Parkinsonism-related falls.
- Diagnose and manage osteoporosis and fragility fractures.
- Direct home safety and environmental modification interventions.
- Coordinate rehabilitation following a fall-related injury.
Clinical vignettes
- A patient with recurrent falls has a significant orthostatic drop in blood pressure. Point: a multifactorial falls assessment is required.
- An elderly woman has hip pain and cannot bear weight after a minor fall; DEXA shows osteoporosis. Dx: Fragility hip fracture.
Polypharmacy & Geriatric Pharmacology
- Apply deprescribing principles to reduce inappropriate polypharmacy.
- Recognize age-related pharmacokinetic and pharmacodynamic changes.
- Identify and manage adverse drug reactions in older adults.
- Apply explicit criteria (e.g. Beers, STOPP/START) for potentially inappropriate medications.
- Direct medication reconciliation across transitions of care.
Clinical vignettes
- An elderly patient on twelve medications develops new confusion after an anticholinergic drug is added. Point: deprescribing guided by tools such as the Beers criteria.
- A patient on long-term benzodiazepines develops falls and daytime drowsiness. Point: gradual taper and review of the original indication.
Incontinence & Geriatric Urology
- Direct the diagnostic evaluation differentiating stress, urge, and overflow incontinence.
- Manage benign prostatic hyperplasia and urinary retention in elderly men.
- Direct the management of fecal incontinence in geriatric patients.
- Apply behavioral and pharmacological approaches to incontinence management.
- Manage catheter-associated complications in elderly patients.
Clinical vignettes
- An elderly woman reports urgency and leakage before reaching the toilet. Dx: Urge incontinence.
- An elderly man has dribbling, a weak stream, and incomplete bladder emptying. Dx: Overflow incontinence secondary to benign prostatic hyperplasia.
Nutrition, Dysphagia & Pressure Injury
- Direct nutritional assessment and management of malnutrition in older adults.
- Manage dysphagia and aspiration risk including swallow assessment.
- Direct the prevention and staged management of pressure injuries.
- Apply enteral and oral nutritional support strategies appropriately.
- Recognize the impact of frailty on nutritional needs.
Clinical vignettes
- A stroke patient coughs while drinking water. Point: a bedside swallow assessment is required before resuming oral intake.
- A bedbound patient develops non-blanching sacral redness. Dx: Stage 1 pressure injury — requires repositioning and offloading.
Cardiovascular & Metabolic Disease in Older Adults
- Manage heart failure with preserved ejection fraction in the frail elderly.
- Manage atrial fibrillation and anticoagulation decisions balancing falls risk.
- Manage orthostatic hypotension and syncope in older adults.
- Manage diabetes mellitus with individualized glycemic targets in frailty.
- Manage hypertension with attention to age-related treatment thresholds.
Clinical vignettes
- An elderly patient has isolated systolic hypertension. Point: cautious, stepwise antihypertensive titration reduces the risk of orthostatic falls.
- A frail diabetic patient has recurrent hypoglycaemia on a tight glycaemic target. Point: glycaemic targets should be relaxed in frail older adults.
Palliative & End-of-Life Care in Geriatrics
- Direct symptom management for older adults with life-limiting illness.
- Facilitate advance care planning and advance directive discussions.
- Apply ethical frameworks to end-of-life decision-making in the elderly.
- Coordinate hospice and palliative care referral for geriatric patients.
- Support bereaved families following the death of an older patient.
Clinical vignettes
- A patient with advanced dementia has recurrent aspiration pneumonia. Point: a goals-of-care discussion regarding feeding tube placement versus comfort-focused care is needed.
- A dying patient develops terminal agitation. Point: symptom-focused comfort medications are prioritised over curative intervention.
Perioperative & Hospital Geriatrics
- Direct preoperative optimization of frail older surgical patients.
- Manage postoperative delirium and functional decline in older patients.
- Coordinate orthogeriatric co-management of hip fracture patients.
- Direct discharge planning to prevent hospital readmission in older adults.
- Apply principles of age-friendly hospital care.
Clinical vignettes
- An elderly patient on warfarin is being prepared for hip surgery. Point: a perioperative anticoagulation bridging plan is required.
- A post-operative elderly patient remains immobile and at risk of deconditioning. Point: early mobilisation protocols reduce hospital-acquired functional decline.
Elder Abuse, Ethics & Long-Term Care
- Recognize and respond to suspected elder abuse or neglect.
- Apply ethical and legal principles to decision-making capacity in older adults.
- Direct the medical oversight of long-term care facility residents.
- Coordinate community and institutional resources for dependent elderly patients.
- Apply guardianship and advance directive principles in geriatric practice.
Clinical vignettes
- An elderly patient has unexplained bruises and appears fearful of their caregiver. Point: screen actively for elder abuse and initiate a safeguarding referral.
- A family disagrees over decision-making for a relative with dementia. Point: a formal capacity assessment and identification of a surrogate decision-maker are required.

Paediatrics Residency

Neonatal Resuscitation & Respiratory Distress
- Direct the resuscitation and stabilization of critically ill neonates.
- Manage respiratory distress syndrome and surfactant therapy in preterm infants.
- Manage meconium aspiration syndrome and persistent pulmonary hypertension of the newborn.
- Direct mechanical ventilation strategies in the neonate.
- Manage transient tachypnea of the newborn and apnea of prematurity.
Clinical vignettes
- A term newborn is floppy at birth and not crying. Point: follow the NRP algorithm — stimulate and provide positive-pressure ventilation if not breathing.
- A preterm infant develops grunting, retractions, and a ground-glass pattern on chest X-ray. Dx: Respiratory distress syndrome — surfactant therapy.
Neonatal Sepsis, Jaundice & NEC
- Manage early- and late-onset neonatal sepsis.
- Direct the management of severe hyperbilirubinemia and exchange transfusion.
- Manage necrotizing enterocolitis including surgical referral criteria.
- Manage neonatal seizures and hypoxic-ischemic encephalopathy including therapeutic hypothermia.
- Direct the long-term neurodevelopmental follow-up of high-risk neonates.
Clinical vignettes
- A preterm neonate develops temperature instability, lethargy, and poor feeding. Dx: Late-onset neonatal sepsis.
- A neonate has abdominal distension, bloody stools, and pneumatosis intestinalis on abdominal X-ray. Dx: Necrotising enterocolitis.
Paediatric Septic Shock & Multi-organ Dysfunction
- Direct the recognition and fluid-refractory management of pediatric septic shock.
- Manage disseminated intravascular coagulation in critically ill children.
- Manage acute respiratory distress syndrome in children.
- Lead pediatric advanced life support in cardiac arrest.
- Manage multi-organ dysfunction syndrome in the pediatric ICU.
Clinical vignettes
- A child presents with fever, cold extremities, prolonged capillary refill, and hypotension. Dx: Cold septic shock — fluid bolus followed by inotropic support.
- A child with sepsis develops oliguria and a rising creatinine. Point: monitor closely for evolving multi-organ dysfunction and adjust drug dosing accordingly.
Paediatric Neurocritical Care
- Manage status epilepticus in children including refractory cases.
- Manage raised intracranial pressure and traumatic brain injury in children.
- Manage acute stroke in childhood.
- Diagnose and manage Guillain-Barré syndrome in children.
- Manage coma and altered consciousness of unclear etiology in children.
Clinical vignettes
- A child after head trauma has a falling GCS and unequal pupils. Dx: Raised intracranial pressure with impending herniation — urgent neuroimaging and management.
- A 2-year-old has a febrile seizure lasting more than 15 minutes. Point: distinguish complex febrile seizure from CNS infection and evaluate accordingly.
Congenital Heart Disease
- Direct the diagnostic work-up of cyanotic and acyanotic congenital heart disease.
- Manage heart failure secondary to left-to-right shunt lesions.
- Manage hypoplastic left heart syndrome and single-ventricle physiology.
- Direct the perioperative management of children undergoing cardiac surgery.
- Manage coarctation of the aorta and duct-dependent lesions.
Clinical vignettes
- A neonate has central cyanosis unresponsive to supplemental oxygen and a single loud S2. Dx: Transposition of the great arteries.
- An infant has failure to thrive and a loud pansystolic murmur at the left sternal border. Dx: Ventricular septal defect.
Acquired Paediatric Cardiac Disease
- Diagnose and manage Kawasaki disease including coronary artery complications.
- Manage acute rheumatic fever and rheumatic carditis.
- Manage pediatric myocarditis and dilated cardiomyopathy.
- Manage pediatric arrhythmias including SVT.
- Manage infective endocarditis in children.
Clinical vignettes
- A child has fever, conjunctivitis, rash, and a strawberry tongue with concern for coronary artery involvement. Dx: Kawasaki disease.
- A child develops migratory joint pain and carditis after streptococcal pharyngitis. Dx: Acute rheumatic fever.
Severe Asthma & Chronic Lung Disease
- Manage status asthmaticus in children.
- Direct step-up biologic therapy in severe pediatric asthma.
- Manage chronic lung disease of prematurity (bronchopulmonary dysplasia).
- Manage cystic fibrosis pulmonary exacerbations.
- Direct the diagnostic work-up of recurrent pneumonia in children.
Clinical vignettes
- A child has severe wheeze, cannot complete sentences, and SpO₂ is 88%. Dx: Life-threatening acute asthma.
- A preterm infant remains oxygen-dependent beyond 36 weeks corrected gestational age. Dx: Bronchopulmonary dysplasia.
Acute Kidney Injury & Nephrotic Syndrome
- Manage acute kidney injury in children including hemolytic uremic syndrome.
- Manage steroid-sensitive and steroid-resistant nephrotic syndrome.
- Manage acute post-streptococcal glomerulonephritis.
- Direct pediatric hypertension work-up and management.
- Direct the indications for renal replacement therapy in children.
Clinical vignettes
- A child has periorbital oedema, frothy urine, and heavy proteinuria. Dx: Nephrotic syndrome (minimal change disease).
- A child develops pallor, low platelets, and a rising creatinine after a diarrhoeal illness. Dx: Haemolytic uraemic syndrome.
GI Bleeding, Liver Failure & Malabsorption
- Manage GI bleeding in the pediatric patient.
- Manage pediatric acute liver failure.
- Direct the diagnostic work-up of failure to thrive and malabsorption including celiac disease.
- Manage inflammatory bowel disease in children.
- Manage biliary atresia and neonatal cholestasis.
Clinical vignettes
- An infant has painless rectal bleeding with a positive technetium scan. Dx: Meckel diverticulum.
- A child develops jaundice, coagulopathy, and encephalopathy after a viral hepatitis illness. Dx: Acute liver failure.
Diabetic Ketoacidosis & Endocrine Emergencies
- Manage diabetic ketoacidosis in children with attention to cerebral edema risk.
- Manage congenital adrenal hyperplasia and adrenal crisis in infants.
- Direct the diagnostic work-up of disorders of growth and puberty.
- Manage congenital hypothyroidism and its neurodevelopmental implications.
- Manage disorders of sex development.
Clinical vignettes
- A child presents with polyuria, vomiting, Kussmaul breathing, and marked hyperglycaemia. Dx: Paediatric DKA — cautious fluid resuscitation to reduce the risk of cerebral oedema.
- A newborn presents with ambiguous genitalia and a salt-wasting crisis. Dx: Congenital adrenal hyperplasia.
Paediatric Oncology & Hematological Emergencies
- Direct the diagnostic work-up of acute lymphoblastic and myeloid leukemia.
- Manage tumor lysis syndrome and febrile neutropenia in children.
- Manage sickle cell crisis and its complications.
- Diagnose and manage severe hemophilia and bleeding disorders in children.
- Manage complications of pediatric bone marrow transplantation.
Clinical vignettes
- A child has pallor, bruising, bone pain, and blasts on peripheral smear. Dx: Acute lymphoblastic leukaemia.
- A child presents with an abdominal mass, hypertension, and haematuria. Dx: Wilms tumour.
Severe Infections, Meningitis & Immunization
- Direct empiric and targeted therapy in pediatric bacterial meningitis.
- Manage congenital and perinatally acquired infections (TORCH).
- Manage severe dengue, malaria, and enteric fever in children.
- Direct the management of pediatric HIV and tuberculosis.
- Manage vaccine-preventable disease outbreaks in a pediatric population.
Clinical vignettes
- An infant has fever, a bulging fontanelle, and irritability. Dx: Bacterial meningitis.
- An unimmunised child develops a barking cough and stridor. Point: consider severe croup or diphtheria and check immunisation status.
Inborn Errors of Metabolism & Genetic Syndromes
- Direct the diagnostic approach to suspected inborn errors of metabolism presenting with acute decompensation.
- Manage acute metabolic decompensation in a known metabolic disorder.
- Direct the evaluation and management of common genetic syndromes (Down, Turner, DiGeorge).
- Coordinate multidisciplinary care for children with developmental disabilities.
- Direct early intervention planning for children with developmental delay.
Clinical vignettes
- A neonate develops poor feeding, lethargy, and metabolic acidosis shortly after starting feeds. Dx: Inborn error of metabolism (e.g. an organic acidaemia).
- An infant has hypotonia, macroglossia, and an umbilical hernia. Dx: Consider congenital hypothyroidism or Beckwith–Wiedemann syndrome.
Paediatric Trauma, Poisoning & Abuse
- Direct the initial resuscitation of the critically injured child.
- Manage pediatric poisoning and toxicological emergencies.
- Manage acute abdominal and surgical emergencies in children (intussusception, appendicitis).
- Recognize and respond to suspected non-accidental injury.
- Direct triage and management of mass casualty events involving children.
Clinical vignettes
- An infant presents with multiple fractures at different stages of healing and an inconsistent history. Dx: Non-accidental injury (child abuse) — requires safeguarding assessment.
- A toddler ingests unknown tablets and becomes drowsy. Point: urgent poisoning assessment and contact with a poison control centre.
Academic Paediatrics, Ethics & Advocacy
- Design and deliver structured teaching for medical students and junior residents.
- Critically appraise pediatric clinical research and apply it to practice.
- Lead a quality improvement project within a pediatric unit.
- Apply ethical principles to consent and decision-making in pediatric care.
- Advocate for child health policy at the institutional or community level.
Clinical vignettes
- A resident is asked to obtain consent for a procedure on a minor from a parent. Point: understand the distinction between parental consent and a minor's assent.
- A paediatrician advocates for vaccine access in an underserved community. Point: the physician's role as a child health advocate extends beyond the clinic.

Management+

Cardiovascular
- Stable angina (ischemic heart disease): Beta-blocker or calcium channel blocker plus antiplatelet and statin first-line; add a second antianginal agent (long-acting nitrate/ranolazine) if symptoms persist, and proceed to coronary angiography with revascularisation for high-risk anatomy or refractory symptoms; monitor heart rate/BP on titration and repeat lipid panel at 4-12 weeks on statin; in renal impairment adjust statin dose and prefer agents with non-renal clearance, and avoid non-dihydropyridine CCBs with concurrent beta-blockade in reduced ejection fraction.
- Essential hypertension: Lifestyle modification plus a single agent (ACE-I/ARB, CCB, or thiazide-like diuretic) started first-line, adding a second and then third agent from different classes if target not met within 4-6 weeks per visit; add a mineralocorticoid antagonist (spironolactone) for resistant hypertension after excluding secondary causes; monitor renal function and potassium 1-2 weeks after starting/uptitrating ACE-I/ARB or spironolactone; avoid ACE-I/ARB in pregnancy (use labetalol/methyldopa/nifedipine instead) and start with lower doses in the elderly given orthostasis risk.
- Atrial fibrillation (rate control): Beta-blocker or rate-limiting CCB first-line, adding digoxin for inadequate control especially in heart failure or sedentary patients; anticoagulate per CHA2DS2-VASc score (DOAC preferred over warfarin unless mechanical valve or significant mitral stenosis); monitor renal function at baseline and at least annually on DOACs since dosing is renally adjusted; reduce DOAC dose or avoid in severe renal impairment (CrCl<15-30 depending on agent), and use warfarin with target INR 2-3 in valvular AF or antiphospholipid syndrome.
- Valvular heart disease (general): Serial echocardiographic surveillance (interval depends on valve/severity) with intervention once criteria for severe symptomatic disease or LV dysfunction are met; escalate to earlier intervention if exercise testing reveals symptoms or falling BP; monitor for endocarditis risk and provide antibiotic prophylaxis only for high-risk procedures in high-risk lesions per current guidance; in pregnancy, severe stenotic lesions may require pre-conception intervention given poor tolerance of the physiological volume load.
- Cardiogenic shock: Inotropic/vasopressor support (norepinephrine first-line, dobutamine for inotropy) with treatment of the precipitant (urgent revascularisation if MI-related); escalate to mechanical circulatory support (IABP, Impella, ECMO) if refractory to pharmacological support; monitor lactate clearance, urine output, and invasive haemodynamics/arterial line; in the elderly or frail, weigh mechanical support risk-benefit carefully given high complication rates.
- Rheumatic heart disease: Secondary penicillin prophylaxis (monthly IM benzathine penicillin) continued for years to decades depending on severity and carditis history, escalating to valve surgery for haemodynamically significant damage; monitor for recurrent carditis and progressive valve dysfunction with periodic echocardiography; in pregnancy, significant mitral stenosis often decompensates in the second trimester and may need balloon valvotomy before delivery.
- Empyema: Chest tube drainage plus targeted IV antibiotics, escalating to intrapleural fibrinolytics or surgical decortication if loculated/organised or drainage fails; monitor clinical response, repeat imaging, and inflammatory markers to guide duration; in immunocompromised or diabetic patients broaden empirical cover and lower the threshold for early surgical referral.
- Bronchiectasis: Airway clearance physiotherapy and treatment of infective exacerbations first-line, escalating to long-term macrolide therapy (azithromycin) in frequent exacerbators and inhaled antibiotics for chronic Pseudomonas colonisation; monitor sputum culture, lung function, and QTc/LFTs on chronic macrolide therapy; avoid macrolides in patients with significant QT prolongation or non-tuberculous mycobacterial infection until excluded.
- Acute ST-elevation myocardial infarction: Primary PCI within 90-120 minutes is preferred; give thrombolysis if PCI unavailable within that window, followed by transfer for rescue/routine PCI if thrombolysis fails or as protocol dictates; dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) and anticoagulation alongside high-intensity statin and beta-blocker/ACE-I once stable; monitor for reperfusion arrhythmias, mechanical complications (VSD, papillary muscle rupture, free wall rupture) and troponin trend; in the elderly or those with high bleeding risk, consider shorter DAPT duration and a less potent P2Y12 agent.
- NSTEMI/unstable angina: Risk stratify (GRACE score) to guide timing of invasive angiography (immediate for very high-risk, within 24-72h for high/intermediate risk); dual antiplatelet therapy and anticoagulation started on admission, with early invasive strategy for high-risk patients; monitor serial troponin and ECG for evolving changes; in CKD, adjust anticoagulant dosing and consider the bleeding-ischaemia trade-off of an invasive strategy.
- Acute pericarditis: NSAIDs plus colchicine as first-line therapy; treat the underlying cause if identified.
- Cardiac tamponade: Urgent pericardiocentesis or surgical drainage is definitive; IV fluids are only a temporising bridge and should not delay drainage; monitor haemodynamics continuously and send fluid for cytology/culture/TB workup; in malignant effusion consider a pericardial window to prevent recurrence.
- Constrictive pericarditis: Diuretics for symptom control of congestion first-line; pericardiectomy is the definitive treatment for refractory or progressive disease, ideally before severe myocardial atrophy develops; monitor for the transient/reversible constrictive phase which may resolve with anti-inflammatory therapy before committing to surgery; surgical risk is elevated in those with long-standing calcific constriction and reduced ejection fraction.
- Infective endocarditis: Prolonged targeted IV antibiotics (typically 4-6 weeks) guided by blood cultures and organism sensitivities, empirical cover broadened while awaiting cultures in acutely unwell patients; valve surgery indicated for heart failure, uncontrolled infection, large mobile vegetations, or recurrent emboli, ideally not delayed once indicated; monitor for new murmurs, emboli, and repeat echocardiography; adjust antibiotic dosing in renal impairment and consider outpatient parenteral therapy only once stable and source controlled.
- Dilated cardiomyopathy: Standard heart-failure therapy (ACE-I/ARB or ARNI, beta-blocker, mineralocorticoid antagonist, SGLT2 inhibitor) titrated to target doses; escalate to device therapy (ICD/CRT) once on optimal medical therapy with persistent low EF, and to transplant/LVAD for advanced refractory disease; monitor renal function/potassium on ACE-I/ARNI/spironolactone combination and repeat echocardiography to reassess EF; avoid ARNI within 36h of ACE-I switch (washout period) and reduce diuretic doses cautiously in pregnancy-associated cardiomyopathy.
- Hypertrophic cardiomyopathy: Beta-blockers or non-dihydropyridine CCBs first-line for symptoms, avoiding vasodilators/high-dose diuretics that worsen outflow obstruction; escalate to septal reduction therapy (myectomy or alcohol ablation) for drug-refractory obstructive symptoms, and ICD implantation for patients meeting sudden death risk criteria; monitor for arrhythmia and outflow gradient on serial echocardiography; screen first-degree relatives given autosomal dominant inheritance, and counsel against competitive sports in high-risk patients.
- Restrictive cardiomyopathy: Diuretics for congestion as symptomatic therapy; treat the underlying infiltrative cause where identifiable (e.g. disease-specific therapy for amyloidosis, iron chelation for haemochromatosis); monitor for progression to advanced heart failure, since restrictive physiology carries a generally poor prognosis without disease-modifying therapy; anticoagulation is often needed given high atrial fibrillation/thrombus risk.
- Wolff-Parkinson-White syndrome: Catheter ablation of the accessory pathway is curative and recommended for symptomatic or high-risk asymptomatic patients (short refractory period on EP study); avoid AV-nodal blocking agents (digoxin, verapamil) in pre-excited atrial fibrillation as they can accelerate conduction down the accessory pathway and precipitate VF; monitor asymptomatic patients with periodic risk stratification, particularly athletes.
- Ventricular tachycardia (sustained): Immediate synchronised cardioversion if haemodynamically unstable; antiarrhythmic therapy (amiodarone/procainamide) and correction of reversible causes (electrolytes, ischaemia) if stable, with ICD evaluation for structural heart disease; monitor QTc on antiarrhythmic therapy and electrolytes (K+, Mg2+) closely; catheter ablation considered for recurrent monomorphic VT despite device therapy.
- Ventricular fibrillation: Immediate defibrillation integrated with high-quality CPR per ACLS algorithm; escalate to amiodarone/lidocaine for refractory VF and treat reversible causes (H's and T's); post-resuscitation, targeted temperature management and urgent coronary angiography if ischaemic cause suspected; ICD implantation is indicated in survivors without a clearly reversible cause.
- Bradyarrhythmia with syncope: Temporary pacing if haemodynamically unstable; permanent pacemaker for persistent symptomatic bradycardia once reversible causes (drugs, electrolytes, hypothyroidism) are excluded; monitor for pacemaker-related complications (lead displacement, infection) post-implant; review and hold AV-nodal blocking medications that may be contributing before committing to a device.
- Complete heart block: Permanent pacemaker implantation is definitive for persistent complete heart block; temporary pacing (transcutaneous or transvenous) is used to bridge unstable patients; monitor for underlying reversible causes (inferior MI, Lyme disease, medication toxicity) which may allow recovery without a permanent device; in congenital complete heart block, pacing thresholds differ and paediatric cardiology input is needed.
- Deep vein thrombosis: Anticoagulation (DOAC or LMWH/warfarin) for at least 3 months, with compression stockings for symptom relief.
- Pulmonary embolism (massive): Systemic thrombolysis (or catheter-directed therapy if bleeding risk precludes systemic lysis) for haemodynamic instability, plus therapeutic anticoagulation and haemodynamic/vasopressor support; monitor for reperfusion bleeding and right heart strain on echocardiography; in recent surgery or high bleeding risk, favour catheter-directed or surgical embolectomy over systemic thrombolysis.
- Pulmonary embolism (non-massive): Therapeutic anticoagulation (DOAC preferred in most patients) guided by risk stratification (PESI score) to determine inpatient versus outpatient management; escalate to thrombolysis only if signs of right heart strain progress to instability; monitor for recurrent VTE and consider thrombophilia workup if unprovoked and young; use LMWH instead of DOACs in active cancer (though DOACs now acceptable in many low-GI-bleed-risk cancers) and in pregnancy.
- Aortic dissection (type A): Emergency surgical repair is definitive given high mortality with delay; blood pressure and heart rate control (beta-blocker first, then vasodilator) while awaiting theatre to reduce shear stress; monitor for malperfusion syndromes (coronary, cerebral, mesenteric, renal, limb) which change urgency and approach; in Marfan/connective tissue disease, root replacement is favoured over repair given recurrence risk.
- Aortic dissection (type B, uncomplicated): Medical management with aggressive heart rate and blood pressure control (beta-blocker plus vasodilator) as first-line; escalate to endovascular repair (TEVAR) for complications such as malperfusion, rupture, refractory pain, or rapid expansion; monitor with serial imaging to detect progression; long-term surveillance imaging is required indefinitely given chronic dissection risk.
- Abdominal aortic aneurysm (unruptured, large): Elective surgical or endovascular repair (EVAR preferred where anatomically suitable) once size threshold (~5.5cm, or smaller with rapid growth/symptoms) is met; surveillance ultrasound at intervals based on size for smaller aneurysms; monitor for endoleak on follow-up imaging after EVAR; in women, intervention is often considered at a smaller diameter given higher rupture risk per size.
- Peripheral arterial disease (claudication): Supervised exercise therapy, antiplatelet and high-intensity statin therapy as first-line, with cilostazol for symptom relief if not contraindicated; escalate to revascularisation (endovascular or surgical) for lifestyle-limiting claudication refractory to medical therapy or for critical limb ischaemia; monitor ankle-brachial index and foot skin integrity, especially in diabetics; avoid cilostazol in heart failure.
- Acute limb ischaemia: Emergency revascularisation (embolectomy, catheter-directed thrombolysis, or bypass depending on cause/extent) plus immediate therapeutic anticoagulation; monitor for reperfusion injury (compartment syndrome, hyperkalaemia, myoglobinuria) after revascularisation; time to intervention is critical - irreversible ischaemia after roughly 6 hours often necessitates primary amputation.
- Varicose veins (symptomatic): Compression stockings and leg elevation first-line; endovenous thermal ablation or foam sclerotherapy for symptomatic truncal reflux refractory to conservative measures, with surgical stripping reserved for select anatomy; monitor for superficial thrombophlebitis and skin changes (lipodermatosclerosis, venous ulceration) suggesting need for earlier intervention.
- Cardiac syncope (structural cause): Treat the underlying structural abnormality definitively (e.g. valve replacement, revascularisation); device therapy (ICD) if syncope relates to a malignant arrhythmia risk; monitor with prolonged rhythm monitoring (implantable loop recorder) if the cause remains unclear despite initial workup; driving restrictions apply until the cause is identified and treated per local regulations.
- Prinzmetal (vasospastic) angina: Calcium channel blockers first-line, with long-acting nitrates as adjunct; avoid non-selective beta-blockers which may worsen spasm by leaving alpha-mediated vasoconstriction unopposed; monitor for coexisting fixed atherosclerotic disease requiring separate management; smoking cessation is essential as smoking is a major trigger.
- Coronary artery ectasia: Antiplatelet/anticoagulant therapy to reduce thrombotic risk within the dilated segments; manage concurrent atherosclerosis as per standard secondary prevention; monitor for aneurysm progression on serial imaging; surgical exclusion considered only for very large or symptomatic aneurysmal segments.
- Left ventricular aneurysm (post-MI): Standard heart-failure and antithrombotic therapy (anticoagulation if mural thrombus present); surgical resection reserved for refractory arrhythmia or heart failure not controlled medically; monitor for thrombus formation and arrhythmia on echocardiography and rhythm monitoring; avoid early high-intensity exercise post-MI until aneurysm risk is assessed.
- Mitral regurgitation (severe, symptomatic): Surgical repair (preferred over replacement where feasible) or replacement for severe symptomatic disease; transcatheter edge-to-edge repair (MitraClip) for high-risk surgical candidates with suitable anatomy; monitor LV size/function on serial echocardiography since intervention timing depends on early signs of ventricular decompensation; in pregnancy, severe MR is generally better tolerated than stenotic lesions but still needs specialist monitoring.
- Mitral stenosis (severe): Percutaneous balloon valvotomy for favourable (non-calcified, non-regurgitant) anatomy; surgical valve replacement otherwise; monitor for atrial fibrillation and thromboembolism, requiring anticoagulation; in pregnancy, severe MS often decompensates in the second/third trimester and balloon valvotomy may be needed before delivery.
- Aortic stenosis (severe, symptomatic): Surgical aortic valve replacement for lower-risk patients; transcatheter aortic valve replacement (TAVR) for intermediate-high surgical risk or elderly patients; avoid vasodilators and excessive diuresis which can precipitate hypotension in fixed-output states; monitor for rapid symptomatic progression, since symptomatic severe AS carries high mortality without intervention.
- Aortic regurgitation (severe, symptomatic): Surgical valve replacement is definitive for symptomatic severe AR or asymptomatic disease with LV dysfunction; vasodilator therapy as a bridge in those not yet meeting surgical criteria or as a surgical risk-reduction measure; monitor LV size/function serially as intervention timing depends on early ventricular changes before irreversible dysfunction develops.
- Tricuspid regurgitation (severe): Treat the underlying cause first (e.g. pulmonary hypertension, left-sided valve disease); surgery reserved for severe primary TR or when performed concurrently with left-sided valve surgery; monitor right heart size/function and signs of right heart failure (oedema, hepatomegaly, ascites); diuretics for symptomatic congestion in the interim.
- Prosthetic valve thrombosis: Urgent thrombolysis or surgical thrombectomy depending on severity, valve position, and thrombus burden; monitor INR closely as subtherapeutic anticoagulation is the usual precipitant; in pregnancy, mechanical valve thrombosis risk is elevated and requires careful anticoagulation bridging strategy.
- Prosthetic valve endocarditis: Prolonged targeted IV antibiotics with early surgical evaluation given high complication risk (abscess, dehiscence, persistent bacteraemia); monitor closely for new conduction abnormalities suggesting perivalvular extension; early-onset (<1 year post-surgery) disease often reflects perioperative contamination and typically requires more aggressive surgical management.
- Atrial flutter: Rate or rhythm control with anticoagulation per stroke risk score, similar to atrial fibrillation; catheter ablation of the cavotricuspid isthmus is often curative and preferred over long-term antiarrhythmic therapy; monitor for conversion to atrial fibrillation which is common; cardiovert only after adequate anticoagulation or TOE exclusion of atrial thrombus if duration >48h or unknown.
- Paroxysmal supraventricular tachycardia: Vagal manoeuvres first-line, then IV adenosine for acute termination; catheter ablation for recurrent episodes is generally curative and preferred over long-term antiarrhythmic drugs; monitor for pre-excitation on baseline ECG which changes drug choice (avoid AV-nodal blockers if WPW-associated); in pregnancy, adenosine remains safe for acute termination.
- Long QT syndrome: Avoidance of QT-prolonging drugs, beta-blocker therapy, and ICD for high-risk patients.
- Brugada syndrome: Avoidance of triggering drugs and prompt fever management (fever can unmask the ECG pattern and precipitate arrhythmia); ICD implantation for high-risk patients (aborted sudden death, syncope with type 1 pattern); monitor asymptomatic patients with periodic risk stratification; screen first-degree relatives given autosomal dominant inheritance.
- Sick sinus syndrome: Permanent pacemaker for symptomatic bradycardia; review and discontinue AV-nodal blocking medications that may be unmasking or worsening the syndrome before committing to a device where feasible; monitor for tachy-brady syndrome requiring concurrent rate control and anticoagulation for the tachyarrhythmic component.
- Acute limb ischaemia (embolic): Emergency embolectomy and immediate anticoagulation; identify the embolic source (atrial fibrillation, mural thrombus, valvular disease) to guide secondary prevention; monitor for reperfusion injury post-revascularisation; long-term anticoagulation is usually required once the source is identified.
- Superior vena cava syndrome (malignant): Urgent stenting for rapid symptom relief in severe/threatening presentations, with radiotherapy or chemotherapy targeting the underlying tumour as definitive therapy; monitor airway and cerebral oedema symptoms in severe cases; avoid upper limb IV access/central lines on the affected side.
- Raynaud's phenomenon (secondary): Calcium channel blockers and cold avoidance first-line; escalate to PDE5 inhibitors or IV prostacyclin analogues for severe/refractory digital ischaemia; treat the underlying connective tissue disease; monitor for digital ulceration requiring more aggressive vasodilator therapy and wound care.
- Takayasu arteritis: Corticosteroids for induction, with immunosuppression (methotrexate, tocilizumab) for relapsing or steroid-refractory disease; monitor inflammatory markers and vascular imaging (MR/CT angiography) for disease activity, as symptoms alone can under-represent ongoing vasculitis; surgical/endovascular intervention for critical stenoses once inflammation is controlled.
- Buerger's disease (thromboangiitis obliterans): Complete and permanent smoking cessation is essential and the only measure proven to alter the disease course; vasodilator therapy and wound care for symptom relief; monitor for digital ulceration/gangrene requiring amputation if smoking continues; revascularisation options are limited given the distal small-vessel pattern.
- Cardiac amyloidosis: Disease-specific therapy (tafamidis for transthyretin type, chemotherapy/autologous transplant for AL type) alongside heart-failure symptom management; monitor for arrhythmia and conduction disease requiring pacing; avoid standard heart-failure agents like ACE-I/ARB and beta-blockers which are often poorly tolerated in restrictive amyloid physiology; anticoagulate for atrial fibrillation given high intracardiac thrombus risk even at low CHA2DS2-VASc scores.
- Constrictive pericarditis (tuberculous): Anti-tubercular therapy plus corticosteroids in the acute phase to reduce progression to constriction; pericardiectomy for established persistent constriction; monitor liver function on anti-TB therapy and for drug interactions (rifampicin with other cardiac medications); TB pericarditis is a common cause of constriction in endemic regions.
- Left bundle branch block with heart failure: Cardiac resynchronisation therapy (CRT) added to standard heart-failure medication for patients with reduced EF and wide LBBB QRS; monitor EF and functional class response to CRT at 3-6 months; ensure guideline-directed medical therapy is optimised before/alongside device implantation rather than as a substitute.
- Coarctation of the aorta: Surgical repair or balloon angioplasty/stenting depending on age at presentation (surgery generally preferred in infancy, stenting favoured in older children/adults); monitor for re-coarctation and hypertension long-term even after successful repair; screen for associated bicuspid aortic valve and berry aneurysms.
- Patent foramen ovale (cryptogenic stroke): Percutaneous closure considered in select patients under 60 with a cryptogenic stroke and high-risk PFO features, alongside antiplatelet therapy; anticoagulation preferred over closure if a separate indication for anticoagulation exists; monitor for recurrent embolic events and reassess for alternative stroke aetiology if events continue post-closure.
- Atrial septal defect (haemodynamically significant): Percutaneous or surgical closure for significant left-to-right shunt (RV volume overload) before irreversible pulmonary vascular disease develops; monitor pulmonary artery pressures, as closure is contraindicated once Eisenmenger physiology is established; in pregnancy, unrepaired large ASDs carry increased risk and closure is ideally done pre-conception.
- Ventricular septal defect (large, symptomatic): Surgical closure to prevent progression to pulmonary hypertension and heart failure, timed in infancy for large defects with heart failure/failure to thrive; monitor for spontaneous closure of small defects which may avoid surgery; assess pulmonary vascular resistance before closure to exclude Eisenmenger physiology where closure would be contraindicated.
- Tetralogy of Fallot: Complete surgical repair, typically performed in infancy; palliative shunt procedures used first in select unstable neonates before definitive repair; monitor long-term for pulmonary regurgitation and right ventricular dysfunction requiring pulmonary valve replacement in adulthood; lifelong cardiology follow-up is required.
- Hypertensive emergency: IV antihypertensive therapy (agent chosen by end-organ involvement, e.g. labetalol/nicardipine) to gradually lower blood pressure by no more than 25% in the first hour to avoid hypoperfusion; monitor for evolving end-organ injury (renal function, neurological status, cardiac markers); in aortic dissection, target heart rate and BP more aggressively and rapidly than in other hypertensive emergencies; in pregnancy (severe pre-eclampsia), use labetalol/hydralazine/nifedipine and add magnesium sulfate for seizure prophylaxis.
- Renovascular hypertension: Angioplasty/stenting for fibromuscular dysplasia (often curative in younger patients); medical therapy (ACE-I/ARB with caution) preferred over revascularisation for atherosclerotic disease unless refractory to medical therapy or declining renal function; monitor renal function and potassium closely after starting ACE-I/ARB given risk of acute kidney injury in bilateral disease; avoid ACE-I/ARB in bilateral renal artery stenosis or stenosis to a solitary kidney.
- Cardiac contusion (traumatic): Cardiac monitoring for arrhythmia in the first 24-48 hours; supportive care as most cases are self-limiting; monitor troponin trend and echocardiography if there is haemodynamic instability or significant ECG changes; treat arrhythmias as they arise per standard protocols.
- Myocarditis (viral): Supportive heart-failure therapy (as tolerated) forms the mainstay; immunosuppression reserved for specific biopsy-proven aetiologies (giant cell myocarditis, eosinophilic myocarditis, sarcoid) rather than routine viral myocarditis; monitor for fulminant presentation requiring mechanical circulatory support, and for arrhythmia; avoid strenuous exercise for 3-6 months post-diagnosis given risk of sudden cardiac death.
Respiratory
- Chronic obstructive pulmonary disease (stable): Long-acting bronchodilator (LAMA/LABA) first-line stepped up to triple therapy (LAMA/LABA/ICS) if frequent exacerbations or blood eosinophils raised; add roflumilast or azithromycin prophylaxis for recurrent exacerbators despite triple therapy; monitor spirometry annually, inhaler technique, and exacerbation frequency; assess for long-term oxygen if resting SpO2 low, and avoid ICS in those with recurrent pneumonia or low eosinophils given limited benefit and infection risk.
- Pulmonary arterial hypertension: Risk-stratify at diagnosis to guide initial mono- or combination PAH-specific therapy (endothelin receptor antagonist, PDE5 inhibitor, prostacyclin pathway agent); escalate to triple therapy or IV prostacyclin for high-risk features or inadequate response; monitor via repeat right heart catheterisation, 6-minute walk, BNP, and functional class at 3-6 months; refer for lung transplant assessment if refractory, and avoid pregnancy given very high maternal mortality.
- Bronchiolitis: Supportive care (oxygen, fluids, nasal suction) is mainstay as it is a self-limiting viral illness; escalate to high-flow nasal cannula or CPAP for increasing work of breathing/hypoxia, with ICU/ventilation for impending respiratory failure; monitor feeding, respiratory rate, and oxygen saturation closely in infants under 3 months or with comorbidities; avoid routine bronchodilators, steroids, or antibiotics as they lack proven benefit.
- Allergic rhinitis: Intranasal corticosteroid first-line, adding a non-sedating antihistamine for breakthrough symptoms; escalate to allergen immunotherapy for severe or poorly controlled disease with confirmed sensitisation; monitor symptom control and adherence, as technique errors commonly limit intranasal steroid efficacy; avoid prolonged topical decongestant use due to rebound rhinitis medicamentosa.
- Chronic sinusitis: Intranasal corticosteroids and saline irrigation first-line, with a prolonged antibiotic course or short oral steroid course for refractory symptoms; escalate to endoscopic sinus surgery for structural obstruction, nasal polyps, or failure of medical therapy; monitor with nasal endoscopy and CT if surgery being considered; screen for aspirin-exacerbated respiratory disease if associated with asthma and nasal polyps.
- Community-acquired pneumonia (moderate severity): Empirical beta-lactam plus macrolide (or respiratory fluoroquinolone) guided by CURB-65 severity; narrow therapy once culture/sensitivity available and switch IV to oral once clinically stable; monitor vitals, oxygenation, and inflammatory markers with reassessment at 48-72 hours if not improving; adjust dosing in renal impairment and consider atypical/aspiration cover in the elderly or those with swallowing difficulty.
- Hospital-acquired pneumonia: Empirical broad-spectrum antibiotics covering resistant Gram-negatives and MRSA per local resistance patterns, de-escalated once cultures return; escalate cover for late-onset disease (>5 days) or prior antibiotic exposure given higher resistant-organism risk; monitor clinical response and repeat cultures if deteriorating; in ICU/ventilated patients apply ventilator-associated pneumonia bundles to prevent recurrence.
- Aspiration pneumonia: Antibiotics covering oral anaerobes and Gram-negatives (e.g. amoxicillin-clavulanate) alongside airway protection and treatment of the underlying aspiration risk (dysphagia, reduced consciousness); escalate to drainage for complicating lung abscess/empyema; monitor swallowing function with formal assessment before resuming oral intake; in stroke or neurodegenerative disease arrange speech-language therapy review to reduce recurrence.
- Lung abscess: Prolonged antibiotics (typically 3-6 weeks, often clindamycin or beta-lactam/beta-lactamase inhibitor) covering anaerobes as first-line, with postural drainage; escalate to percutaneous or surgical drainage for large abscesses, failure to improve, or suspected malignant obstruction; monitor with serial chest imaging to confirm resolution; investigate for underlying bronchial obstruction (tumour, foreign body) in non-resolving or atypical cases.
- Pneumothorax (primary spontaneous, small): Observation with high-flow oxygen alone is appropriate for small, minimally symptomatic pneumothoraces; escalate to needle aspiration or chest tube for larger or symptomatic pneumothoraces; monitor with repeat chest X-ray until resolution and advise against air travel/diving until fully resolved; refer for pleurodesis or surgery after a first recurrence or in high-risk occupations (pilots, divers).
- Tension pneumothorax: Immediate needle decompression followed by chest tube insertion.
- Acute exacerbation of asthma: Nebulised salbutamol/ipratropium plus systemic corticosteroids first-line, escalating to IV magnesium sulfate or aminophylline for severe/life-threatening features; ICU referral and consideration of intubation for silent chest, exhaustion, or rising CO2; monitor peak flow, oxygen saturation, and work of breathing serially, with arterial blood gas in severe cases; in pregnancy treat as aggressively as in non-pregnant patients since hypoxia poses greater fetal risk than medication.
- Acute exacerbation of COPD: Bronchodilators, systemic corticosteroids, and antibiotics (if increased sputum purulence) first-line; escalate to non-invasive ventilation for hypercapnic respiratory failure with acidosis, and invasive ventilation if NIV fails or is contraindicated; monitor arterial blood gases serially and titrate oxygen to avoid hypercapnia in chronic retainers; use controlled oxygen therapy targeting SpO2 88-92% in known CO2 retainers.
- Interstitial lung disease (idiopathic pulmonary fibrosis): Antifibrotic therapy (pirfenidone or nintedanib) first-line to slow progression, as no therapy reverses established fibrosis; escalate to lung transplant assessment for progressive disease despite antifibrotics; monitor pulmonary function tests (FVC, DLCO) every 3-6 months and treat acute exacerbations with high-dose steroids while excluding infection; avoid long-term prednisone/immunosuppression monotherapy, which lacks benefit and may cause harm in IPF specifically.
- Sarcoidosis (symptomatic pulmonary): Observation alone for asymptomatic stage I disease; oral corticosteroids first-line for symptomatic pulmonary or extrapulmonary disease, adding a steroid-sparing agent (methotrexate/azathioprine) for relapsing or steroid-refractory disease; monitor pulmonary function, chest imaging, and calcium (risk of hypercalcaemia from granuloma-mediated vitamin D activation); screen for cardiac and neurological involvement given risk of arrhythmia and sudden death.
- Obstructive sleep apnoea: Weight loss and CPAP first-line for moderate-severe disease based on polysomnography severity; mandibular advancement devices as an alternative for mild-moderate disease or CPAP intolerance; escalate to upper airway surgery in select anatomical cases; monitor adherence and symptom/daytime sleepiness response, and screen for cardiovascular risk (hypertension, arrhythmia) given strong association.
- Pulmonary tuberculosis (drug-sensitive): Standard 6-month regimen (2 months HRZE intensive phase, 4 months HR continuation) first-line under directly observed therapy where possible; extend continuation phase for cavitary disease with positive 2-month culture; monitor sputum smear/culture conversion, liver function (hepatotoxicity risk), and visual acuity on ethambutol; adjust doses in pregnancy (avoid streptomycin) and in renal/hepatic impairment.
- Pleural effusion (malignant): Therapeutic thoracentesis for symptom relief and diagnosis first-line; escalate to indwelling pleural catheter or pleurodesis (talc) for recurrent effusions in patients with reasonable prognosis; monitor for re-accumulation and trapped lung (failure of full re-expansion) which limits pleurodesis success; choice between IPC and pleurodesis depends on expected survival and performance status.
- Chylothorax: Dietary modification (medium-chain triglycerides) or bowel rest with total parenteral nutrition first-line alongside drainage; escalate to octreotide/somatostatin analogue for persistent leak, and surgical thoracic duct ligation or embolisation for high-output or refractory chylothorax; monitor triglyceride level of pleural fluid to confirm diagnosis and daily output to gauge response; correct nutritional and immunological deficits from chronic lymph loss.
- Cystic fibrosis (pulmonary): Airway clearance therapy and CFTR modulator therapy (if genotype-eligible) form the backbone of care, with inhaled mucolytics (dornase alfa, hypertonic saline); treat exacerbations with targeted IV antibiotics against chronic colonising organisms (Pseudomonas); monitor lung function, sputum culture, and nutritional status regularly; CFTR modulators have transformed prognosis but require monitoring of liver function and cataracts.
- Acute respiratory distress syndrome: Lung-protective ventilation (low tidal volume ~6mL/kg predicted body weight, plateau pressure <30cmH2O) is first-line; escalate to prone positioning for moderate-severe hypoxaemia and neuromuscular blockade or ECMO for refractory cases; monitor driving pressure, oxygenation trends, and fluid balance (conservative strategy preferred once haemodynamically stable); treat the underlying precipitant (sepsis, aspiration, pancreatitis) concurrently.
- Pulmonary alveolar proteinosis: Whole-lung lavage is definitive first-line therapy for symptomatic autoimmune PAP; inhaled or subcutaneous GM-CSF is an alternative for milder disease; monitor with serial CT and pulmonary function, as spontaneous remission can occur; investigate for secondary causes (haematological malignancy, dust exposure, immunodeficiency) which change management from lavage-focused to treating the underlying cause.
- Hypersensitivity pneumonitis: Antigen avoidance is the essential first-line intervention; add corticosteroids for symptomatic or fibrosing disease, with antifibrotics considered for progressive fibrotic HP; monitor pulmonary function and HRCT for progression to fibrosis; occupational cases require environmental/workplace modification and, in some, mandatory redeployment.
- Occupational asthma: Complete removal from the causative workplace exposure is the definitive first-line measure, as continued exposure worsens long-term prognosis even with medical therapy; standard asthma pharmacotherapy is used adjunctively; monitor serial peak flow at work versus away from work to confirm the diagnosis; early recognition and workplace change substantially improve the chance of full recovery.
- Pneumoconiosis (coal worker's): No disease-modifying therapy exists; management is supportive (bronchodilators, pulmonary rehabilitation) with further dust exposure avoidance to prevent progression; escalate to lung transplant assessment in progressive massive fibrosis with respiratory failure; monitor for progression to progressive massive fibrosis and screen for tuberculosis and connective tissue disease association (Caplan syndrome).
- Asbestosis: Supportive management (smoking cessation, pulmonary rehabilitation, oxygen if hypoxic) as no specific therapy reverses fibrosis; further asbestos exposure must be eliminated; monitor with serial pulmonary function and chest imaging, and screen for mesothelioma and lung cancer given markedly increased risk, particularly with concurrent smoking; occupational compensation assessment is often relevant.
- Mesothelioma: Multimodal therapy (chemotherapy +/- surgery +/- radiotherapy) for surgically resectable disease in fit patients; palliative chemotherapy/immunotherapy for unresectable/metastatic disease; monitor with imaging response assessment and manage recurrent pleural effusions with pleurodesis/indwelling catheter; overall prognosis remains poor and early palliative care involvement is appropriate.
- Pulmonary hypertension (group 1): See pulmonary arterial hypertension management; risk-stratified PAH-specific therapy escalated to combination or parenteral prostacyclin for high-risk disease; monitor via right heart catheterisation and functional testing; distinguish carefully from other PH groups (left heart disease, lung disease, chronic thromboembolic) as management differs substantially and misclassification leads to inappropriate therapy.
- Chronic thromboembolic pulmonary hypertension: Pulmonary endarterectomy is potentially curative and first-line for surgically accessible disease in operable patients; balloon pulmonary angioplasty or PAH-specific therapy (riociguat) for inoperable or residual disease; lifelong anticoagulation is required regardless of intervention; monitor with V/Q scan, right heart catheterisation, and functional class; refer early to an expert CTEPH centre as operability assessment is specialised.
- Empyema necessitans: Chest tube drainage of the underlying empyema plus targeted IV antibiotics and drainage/debridement of the extrathoracic collection; escalate to surgical decortication if loculated or if drainage is inadequate; monitor clinical response and repeat imaging; consider underlying tuberculosis or actinomycosis as causes, particularly in endemic settings, as these require prolonged specific therapy.
- Bronchopleural fistula: Chest tube drainage and infection control first-line, with nutritional optimisation; escalate to surgical closure (with muscle flap) or bronchoscopic sealant/valve placement for persistent fistulae; monitor for ongoing air leak and signs of empyema; ventilator strategies should minimise positive pressure across the fistula where mechanical ventilation is required.
- Mediastinitis (acute): Urgent surgical debridement plus broad-spectrum IV antibiotics (covering mixed aerobic/anaerobic flora, especially post-oesophageal perforation or sternotomy) is first-line given high mortality if delayed; monitor haemodynamics closely as septic shock is common; identify and control the source (oesophageal perforation, descending cervical infection, sternal wound) as source control determines outcome.
- Diaphragmatic paralysis (unilateral): Observation is appropriate for asymptomatic unilateral paralysis; symptomatic patients benefit from diaphragmatic plication to improve dyspnoea and lung mechanics; monitor pulmonary function and symptoms, and investigate for an underlying cause (phrenic nerve injury, malignancy, cervical spine disease); bilateral involvement is more likely to need nocturnal non-invasive ventilation.
- Chronic cough (unexplained): Stepwise evaluation and empirical treatment trials for the common treatable causes (upper airway cough syndrome, asthma/cough-variant asthma, GORD) first-line; escalate to specialist referral and consideration of neuromodulator therapy (gabapentin, low-dose morphine) or speech therapy for refractory cough hypersensitivity; monitor response to each sequential trial rather than treating empirically in combination; exclude ACE-inhibitor-induced cough by medication review.
- Acute bronchitis: Supportive care (analgesia, fluids) is first-line as it is usually viral and self-limiting; avoid routine antibiotics unless pertussis or bacterial superinfection is suspected; monitor for red flags (high fever, focal signs, hypoxia) suggesting evolving pneumonia; in COPD patients treat as an exacerbation if increased sputum purulence is present.
- Whooping cough (pertussis): Macrolide antibiotics first-line, most effective if started early (catarrhal phase) to reduce transmission though less so once paroxysmal cough is established; supportive care and close monitoring of infants for apnoea/cyanotic spells, who are at highest risk of severe disease; contact prophylaxis with macrolides for close contacts, especially unimmunised infants and pregnant women near term.
- Pulmonary nodule (indeterminate, low risk): Serial CT surveillance at intervals guided by nodule size and risk (Fleischner criteria) is first-line for low-risk nodules; escalate to PET-CT or biopsy for growing nodules or high-risk features; monitor growth rate as the key discriminator of malignancy; in high-risk smokers with larger nodules, earlier tissue diagnosis is warranted rather than prolonged surveillance.
- Bronchogenic cyst (symptomatic): Surgical excision is first-line for symptomatic cysts (infection, compression, haemoptysis) given risk of recurrent infection and rare malignant transformation; asymptomatic incidental cysts may be observed with imaging follow-up; monitor for secondary infection which can complicate surgical planning; thoracoscopic resection is preferred where anatomically feasible.
- Massive haemoptysis: Airway protection (lateral decubitus positioning with bleeding side down, selective intubation if needed) and urgent bronchial artery embolisation is first-line definitive treatment; surgery reserved for embolisation failure or an anatomically resectable localised source; monitor airway patency and haemodynamics continuously as asphyxiation, not exsanguination, is the primary cause of death; identify and treat the underlying cause (TB, bronchiectasis, malignancy, aspergilloma).
- Tracheal stenosis (post-intubation): Endoscopic dilation with or without laser/stenting first-line for short-segment stenosis; surgical tracheal resection and reconstruction for longer-segment or recurrent stenosis in suitable candidates; monitor for restenosis after endoscopic therapy, which is common; prevention through cuff pressure monitoring during prolonged intubation reduces incidence.
- Chronic respiratory failure (home oxygen dependent): Long-term oxygen therapy (>15 hours/day) improves survival in chronic hypoxaemic respiratory failure meeting criteria; add home non-invasive ventilation for hypercapnic failure, particularly in COPD with persistent hypercapnia post-exacerbation; monitor oxygen saturation, arterial blood gases, and adherence; avoid excessive oxygen flow in CO2 retainers to prevent worsening hypercapnia.
- Eosinophilic pneumonia: Oral corticosteroids first-line, with rapid and often dramatic clinical response distinguishing this from most other ILDs; taper slowly given risk of relapse, particularly in chronic eosinophilic pneumonia; monitor peripheral eosinophil count and chest imaging for resolution; identify and remove any causative drug or exposure where relevant.
Gastrointestinal
- Gastroesophageal reflux disease: Lifestyle measures plus PPI first-line, stepping down to lowest effective dose once controlled; escalate to endoscopy for alarm features (dysphagia, weight loss, bleeding, age >55 with new symptoms) and to anti-reflux surgery (fundoplication) for refractory symptoms or large hiatus hernia; monitor for Barrett's oesophagus in long-standing disease; avoid long-term high-dose PPI without reassessment given bone/renal/infection signals in observational data.
- Gastric carcinoma: Surgical resection with lymphadenectomy is curative-intent first-line for resectable disease, with perioperative chemotherapy for locally advanced tumours; palliative chemotherapy or best supportive care for metastatic disease; monitor nutritional status and for anastomotic leak/dumping syndrome post-gastrectomy; screen relatives in hereditary diffuse gastric cancer (CDH1) families.
- Hemorrhoids and fistula-in-ano: Fibre, fluids, and topical therapy first-line for grade I-II haemorrhoids, escalating to rubber band ligation or haemorrhoidectomy for higher grade/refractory disease; fistula-in-ano requires surgical management (fistulotomy for simple, seton for complex/high tracts) to avoid incontinence; monitor for recurrence and for underlying Crohn's disease in complex or recurrent fistulae.
- Abdominal wall hernia: Elective mesh repair first-line for symptomatic reducible hernias; emergency surgery for irreducible, obstructed, or strangulated hernia given risk of bowel ischaemia; monitor for recurrence and mesh-related complications (infection, chronic pain); watchful waiting is reasonable for minimally symptomatic inguinal hernia in low-risk patients.
- Anorectal abscess: Urgent incision and drainage is definitive, with antibiotics reserved for surrounding cellulitis, immunocompromise, or systemic sepsis rather than as a substitute for drainage; monitor for evolution into a chronic fistula-in-ano, which occurs in a substantial minority; underlying Crohn's disease should be considered in recurrent or complex abscesses.
- Urinary tract infection: Empirical antibiotics guided by local resistance patterns, adjusted once culture sensitivities are available.
- Urinary tract calculi: Analgesia and hydration for small stones; lithotripsy or ureteroscopy for larger/obstructing stones.
- IgA nephropathy: ACE-inhibitor/ARB for proteinuria control; corticosteroids for progressive disease with preserved renal function.
- Lupus nephritis: Induction immunosuppression (corticosteroids plus cyclophosphamide or mycophenolate) followed by maintenance therapy.
- Membranous nephropathy: ACE-inhibitor/ARB for proteinuria, with immunosuppression (e.g. rituximab) for high-risk or progressive disease.
- Acute appendicitis: Appendicectomy (laparoscopic preferred) first-line, with antibiotics alone as a selective alternative for uncomplicated appendicitis in appropriate patients; broad-spectrum IV antibiotics plus urgent surgery for perforated/complicated disease; monitor for post-operative collection; in pregnancy, surgery should not be delayed given higher complication rates with expectant management.
- Acute cholecystitis: Early laparoscopic cholecystectomy (within 72h) first-line; percutaneous cholecystostomy for those too unstable for surgery; IV antibiotics and analgesia as supportive care throughout; monitor for progression to gangrenous cholecystitis or perforation; in pregnancy, surgery is preferred in the second trimester when feasible.
- Choledocholithiasis: ERCP with sphincterotomy and stone extraction first-line, followed by cholecystectomy (same admission where possible) to prevent recurrence; monitor liver function and for post-ERCP pancreatitis/cholangitis; in pregnancy, ERCP with abdominal shielding is preferred over surgery for symptomatic stones.
- Acute pancreatitis (mild): Aggressive IV fluid resuscitation, analgesia, and early oral feeding as tolerated (rather than prolonged fasting) first-line; identify and address the cause (cholecystectomy for gallstone pancreatitis during the same admission); monitor for organ dysfunction using severity scoring; avoid prophylactic antibiotics in the absence of infected necrosis.
- Acute pancreatitis (severe/necrotising): ICU-level supportive care with aggressive fluid resuscitation and organ support first-line; delay intervention on necrosis (drainage/necrosectomy) until walled-off (typically >4 weeks) unless infected necrosis with clinical deterioration mandates earlier action; monitor for infected necrosis (fever, rising inflammatory markers) and multi-organ failure; nutritional support (enteral preferred over parenteral) should start early.
- Chronic pancreatitis: Analgesia, pancreatic enzyme replacement, and alcohol/smoking cessation first-line; escalate to endoscopic or surgical decompression for ductal obstruction/refractory pain; monitor for diabetes, malabsorption/steatorrhoea, and pancreatic cancer risk (particularly hereditary pancreatitis); coeliac plexus block can help refractory pain unresponsive to medical therapy.
- Peptic ulcer disease: PPI first-line with H. pylori eradication therapy if positive (triple/quadruple regimen); stop or minimise NSAIDs/aspirin where possible, adding PPI co-prescription if they must continue; monitor for healing endoscopically in gastric ulcers to exclude malignancy; test-of-cure for H. pylori is recommended given eradication failure rates.
- Perforated peptic ulcer: Urgent surgical repair (omental patch) is definitive, with non-operative management (NG decompression, IV PPI, antibiotics) reserved for selected stable patients with sealed perforation on imaging; monitor for sepsis and intra-abdominal collection; H. pylori eradication and NSAID cessation post-recovery reduce recurrence.
- Upper gastrointestinal bleeding (variceal): Vasoactive drugs (terlipressin/octreotide) plus prophylactic antibiotics started immediately, with endoscopic band ligation within 12h as definitive therapy; escalate to TIPS or balloon tamponade for refractory bleeding; monitor haemoglobin, for hepatic encephalopathy, and rebleeding; beta-blockers for secondary prophylaxis once stabilised.
- Upper gastrointestinal bleeding (non-variceal): IV PPI and endoscopy within 24h first-line, with endoscopic haemostasis (clips, thermal, injection) for high-risk stigmata; risk-stratify with Glasgow-Blatchford/Rockall scores to guide admission and timing; monitor haemoglobin and haemodynamics; interventional radiology embolisation or surgery for failed endoscopic control.
- Lower gastrointestinal bleeding: Resuscitation first, then colonoscopy once stabilised (or CT angiography if actively bleeding and unstable) to localise and treat the source; escalate to interventional radiology embolisation or surgery if endoscopic control fails; monitor haemoglobin trend; most cases (diverticular, angiodysplasia) settle spontaneously with supportive care.
- Acute diverticulitis (uncomplicated): Oral antibiotics and liquid diet on an outpatient basis for mild uncomplicated disease (or observation alone in selected low-risk patients per some guidelines); escalate to admission and IV antibiotics for systemic upset or comorbidity; monitor for progression to abscess/perforation; colonoscopy after resolution to exclude malignancy, avoided during the acute phase given perforation risk.
- Diverticular abscess: IV antibiotics plus percutaneous drainage for abscesses >3-4cm first-line; emergency surgery (Hartmann's procedure) for generalised peritonitis or drainage failure; monitor for recurrence, which may prompt elective resection after recovery; interval colonoscopy is required to exclude underlying malignancy.
- Bowel obstruction (small bowel, uncomplicated): NG decompression, IV fluids, and correction of electrolytes first-line ('drip and suck'), which resolves most adhesional obstructions; escalate to surgery for failure to improve within 48-72h, or immediately for signs of strangulation/ischaemia; monitor for peritonism and lactate as markers of compromised bowel.
- Volvulus (sigmoid): Endoscopic decompression first-line for uncomplicated sigmoid volvulus, followed by elective resection given high recurrence risk; emergency surgery for signs of ischaemia, perforation, or failed endoscopic detorsion; monitor for recurrence, particularly common before definitive resection; caecal volvulus generally requires surgery rather than endoscopic reduction.
- Ulcerative colitis (moderate flare): Oral/topical corticosteroids and 5-ASA first-line for induction, adding biologic therapy (anti-TNF, vedolizumab) for steroid-refractory or steroid-dependent disease; monitor CRP, faecal calprotectin, and for toxic megacolon in severe flares; screen for colorectal cancer with regular colonoscopic surveillance in long-standing extensive disease.
- Crohn's disease (active): Corticosteroids for induction with early introduction of immunomodulator (azathioprine) or biologic (anti-TNF) for moderate-severe or steroid-dependent disease; surgery for stricturing/fistulising disease refractory to medical therapy; monitor nutritional status, CRP/calprotectin, and screen for TB/hepatitis B before biologics; smoking cessation is a key modifiable factor worsening course.
- Irritable bowel syndrome: Dietary modification (low FODMAP trial) and reassurance first-line; add antispasmodics, laxatives, or antidiarrhoeals targeted to the predominant symptom pattern, with low-dose tricyclics or gut-directed psychotherapy for refractory pain; monitor for red flags (weight loss, bleeding, nocturnal symptoms, age >50 new onset) prompting investigation to exclude organic disease.
- Celiac disease: Strict lifelong gluten-free diet is the only effective treatment; monitor coeliac serology and symptom response, and repeat duodenal biopsy if response is inadequate to exclude refractory disease; screen for osteoporosis, iron/B12/folate deficiency, and associated autoimmune conditions (type 1 diabetes, thyroid disease); avoid empirical gluten withdrawal before serology/biopsy as this reduces diagnostic accuracy.
- Acute viral gastroenteritis: Oral rehydration therapy first-line, escalating to IV fluids for significant dehydration or intractable vomiting; antiemetics may help in children/adults with ongoing vomiting; monitor hydration status and electrolytes in severe cases; antibiotics are not indicated and antimotility agents are avoided if bloody diarrhoea/high fever suggests bacterial cause.
- Clostridioides difficile colitis: Oral vancomycin or fidaxomicin first-line (metronidazole now reserved for mild disease where the others are unavailable); escalate to oral vancomycin plus IV metronidazole for fulminant disease, with surgery (colectomy) for toxic megacolon/perforation; monitor for recurrence, which is common and may need fidaxomicin or faecal microbiota transplant; stop the precipitating antibiotic where possible.
- Colorectal carcinoma (resectable): Surgical resection with lymphadenectomy first-line, with neoadjuvant chemoradiotherapy for locally advanced rectal cancer and adjuvant chemotherapy for node-positive disease; monitor with surveillance colonoscopy and CEA/imaging post-resection for recurrence; screen first-degree relatives given familial risk, and test for Lynch syndrome in appropriate cases.
- Hepatocellular carcinoma: Resection or liver transplantation for early-stage disease within transplant criteria (Milan criteria); locoregional therapy (ablation, TACE) for unresectable disease confined to the liver, and systemic therapy (tyrosine kinase inhibitors/immunotherapy) for advanced disease; monitor AFP and imaging surveillance every 6 months in cirrhotic patients for early detection; manage underlying cirrhosis/hepatitis concurrently.
- Liver abscess (amoebic): Metronidazole first-line, which is effective for most cases without drainage; add percutaneous aspiration/drainage for large abscesses (>5cm), diagnostic uncertainty, or failure to respond within 3-5 days; monitor clinical and radiological resolution, which can lag behind symptomatic improvement; luminal agent (paromomycin) after treatment to eradicate intestinal colonisation.
- Acute cholangitis: Urgent IV antibiotics plus biliary decompression (ERCP first-line) is definitive, with the timing of ERCP guided by severity (emergency for septic shock); percutaneous transhepatic drainage if ERCP fails/unavailable; monitor for sepsis and organ dysfunction; cholecystectomy after recovery if gallstones are the cause.
- Portal hypertension with ascites: Sodium restriction and diuretics (spironolactone plus furosemide) first-line; escalate to large-volume paracentesis with albumin replacement for refractory/tense ascites, and TIPS for recurrent refractory ascites; monitor renal function and electrolytes on diuretics; avoid NSAIDs and excessive diuresis, which risk hepatorenal syndrome.
- Spontaneous bacterial peritonitis: Empirical IV antibiotics (third-generation cephalosporin) started promptly on diagnostic paracentesis (neutrophils >250/mm3), plus IV albumin to reduce hepatorenal syndrome risk; monitor renal function and repeat paracentesis if not improving; secondary antibiotic prophylaxis (norfloxacin) after an episode given high recurrence risk.
- Hepatic encephalopathy: Lactulose first-line, titrated to 2-3 soft stools/day, adding rifaximin for recurrent/refractory episodes; identify and treat precipitants (infection, GI bleeding, electrolyte disturbance, constipation); monitor mental status and ammonia trend (though ammonia correlates imperfectly with severity); avoid sedatives which can precipitate or worsen encephalopathy.
- Achalasia: Pneumatic dilatation or laparoscopic Heller myotomy first-line (comparable efficacy), with peroral endoscopic myotomy (POEM) an emerging alternative; botulinum toxin injection reserved for those unfit for definitive therapy given limited duration of effect; monitor for reflux post-myotomy, which is common and may need long-term PPI; barium swallow/manometry confirms diagnosis and excludes pseudoachalasia.
- Anal fissure: Topical GTN or diltiazem plus fibre/stool softeners first-line; escalate to botulinum toxin injection or lateral internal sphincterotomy for chronic fissures refractory to topical therapy; monitor healing at 6-8 weeks; sphincterotomy carries a small risk of incontinence, weighed against persistent symptoms.
- Zenker's diverticulum: Endoscopic or open surgical myotomy with diverticulectomy/diverticulopexy for symptomatic disease; small asymptomatic diverticula can be observed; monitor for aspiration risk pre-intervention and recurrence post-procedure; regurgitation of undigested food and halitosis are characteristic presenting symptoms guiding diagnosis.
- Barrett's oesophagus (no dysplasia): PPI therapy and surveillance endoscopy at intervals guided by segment length (typically 3-5 yearly) first-line; no endoscopic ablation indicated without dysplasia; monitor for progression to dysplasia on surveillance biopsies; lifestyle reflux measures should continue alongside acid suppression.
- Barrett's oesophagus (high-grade dysplasia): Endoscopic eradication therapy (radiofrequency ablation with or without endoscopic mucosal resection of visible lesions) first-line given high progression risk to cancer; oesophagectomy reserved for those with invasive cancer or endoscopically unresectable disease; monitor with intensive surveillance post-ablation for recurrence.
- Oesophageal carcinoma (resectable): Neoadjuvant chemoradiotherapy followed by oesophagectomy first-line for locally advanced resectable disease; endoscopic resection alone may suffice for early T1a disease; monitor nutritional status and for anastomotic leak post-operatively; palliative stenting/chemotherapy for unresectable or metastatic disease.
- Oesophageal varices (primary prophylaxis): Non-selective beta-blockers or endoscopic variceal band ligation first-line for medium/large varices, chosen based on patient factors and local expertise; monitor for beta-blocker tolerance (heart rate, blood pressure) or band ligation-related ulceration; repeat surveillance endoscopy for those not on prophylaxis with small varices.
- Mallory-Weiss tear: Supportive care as most bleeds are self-limiting; endoscopic haemostasis (clips, injection) for active bleeding at endoscopy; monitor haemoglobin and haemodynamics; identify and address the precipitant (forceful vomiting/retching, often alcohol-related).
- Boerhaave syndrome (oesophageal rupture): Urgent surgical repair or oesophagectomy is first-line for most cases given high mortality if untreated, with covered stenting/drainage as an alternative in selected stable patients with contained perforation; broad-spectrum antibiotics and NPO status alongside; monitor for mediastinitis and sepsis; delay in diagnosis significantly worsens outcome, so maintain high suspicion after vomiting with chest pain.
- Eosinophilic oesophagitis: Proton pump inhibitor trial first-line (a subset respond, termed PPI-responsive oesophageal eosinophilia), escalating to topical swallowed corticosteroids or dietary elimination for non-responders; monitor with repeat biopsy to confirm histological remission, as symptoms correlate imperfectly with inflammation; oesophageal dilatation for stricturing complications.
- Gastric outlet obstruction (benign): Endoscopic balloon dilatation first-line for peptic stricture-related obstruction, with surgery (gastrojejunostomy) for recurrent/refractory cases; treat underlying peptic ulcer disease/H. pylori; monitor for recurrence and nutritional status; malignancy must be excluded before assuming a benign cause.
- Zollinger-Ellison syndrome (gastrinoma): High-dose PPI first-line for acid hypersecretion control; localise and surgically resect the gastrinoma where feasible, particularly in sporadic disease, as this offers potential cure; monitor fasting gastrin and secretin stimulation test; screen for MEN1 syndrome given association, which alters surgical approach.
- Gastroparesis: Dietary modification (small frequent low-fat, low-fibre meals) and prokinetics (metoclopramide, domperidone) first-line; escalate to gastric electrical stimulation or venting/feeding jejunostomy for refractory severe disease; monitor glycaemic control in diabetic gastroparesis, as poor control worsens motility; limit metoclopramide duration given extrapyramidal risk.
- Small bowel bacterial overgrowth: Antibiotic course (rifaximin or other broad-spectrum agent) first-line, often cycled given high recurrence; treat the underlying predisposing cause (stricture, dysmotility, prior surgery) where identifiable; monitor for nutritional deficiencies (B12, fat-soluble vitamins) and symptom recurrence; hydrogen/methane breath testing supports diagnosis.
- Mesenteric ischaemia (acute): Urgent surgical or endovascular revascularisation plus resection of non-viable bowel is definitive, with anticoagulation started promptly once diagnosis suspected; broad-spectrum antibiotics given bacterial translocation risk; monitor lactate and for peritonism indicating bowel infarction; high mortality reflects the need for rapid diagnosis and intervention.
- Chronic mesenteric ischaemia: Endovascular angioplasty/stenting first-line for suitable anatomy, with open bypass reserved for extensive disease or endovascular failure; monitor for symptom recurrence (postprandial pain, weight loss) and in-stent restenosis; address cardiovascular risk factors given shared atherosclerotic aetiology.
- Ischaemic colitis: Supportive care (fluids, bowel rest, antibiotics if signs of infection) first-line for most cases, which are transient and resolve without intervention; escalate to surgery for peritonitis, perforation, or gangrenous colitis; monitor for stricture formation as a late complication; identify and correct any precipitating hypoperfusion event.
- Toxic megacolon: IV corticosteroids (or antibiotics if C. difficile-related) plus bowel rest and NG decompression first-line, with surgical colectomy for deterioration or failure to improve within 24-72h; monitor abdominal girth, vital signs, and for perforation; avoid antimotility agents and opioids which can precipitate the condition.
- Microscopic colitis: Budesonide first-line for induction of remission, which has the strongest evidence base; stop implicated drugs (NSAIDs, PPIs, SSRIs) where possible as they are associated triggers; monitor symptom response and relapse, which is common on stopping therapy; distinguish from IBD on biopsy given normal endoscopic appearance.
- Rectal prolapse: Surgical repair (rectopexy, abdominal or perineal approach depending on fitness) is definitive for full-thickness prolapse; pelvic floor exercises/biofeedback for mucosal prolapse or as an adjunct; monitor for recurrence, more common with perineal approaches; assess for coexisting pelvic floor dysfunction and incontinence.
- Anal fistula (complex): Seton drainage first-line to control sepsis while preserving continence, with definitive repair (advancement flap, LIFT procedure) once inflammation settles; avoid fistulotomy for high/complex tracts given incontinence risk; monitor for underlying Crohn's disease, which changes management priorities toward medical control first.
- Pilonidal sinus disease: Incision and drainage for acute abscess first-line, with definitive excision (with or without flap closure) for chronic/recurrent disease; hygiene and hair removal reduce recurrence; monitor wound healing, as recurrence and delayed healing are common with midline closure techniques.
- Perianal abscess: Prompt incision and drainage is definitive; antibiotics as an adjunct only in immunocompromise, systemic sepsis, or extensive cellulitis; monitor for fistula formation on follow-up; recurrent or complex abscesses warrant assessment for underlying Crohn's disease.
- Acute mesenteric adenitis: Supportive care (analgesia, hydration) first-line, as this is typically a self-limiting viral-associated condition; monitor for resolution and exclude appendicitis as the key differential, particularly in children; imaging (ultrasound) helps distinguish the two and avoids unnecessary surgery.
- Cholangiocarcinoma (resectable): Surgical resection (with liver resection/transplant for select hilar tumours) first-line for early localised disease; biliary drainage (ERCP/PTC stenting) for obstructive jaundice pre-operatively or in unresectable disease; monitor liver function and CA 19-9; systemic chemotherapy for unresectable/metastatic disease.
- Gallbladder carcinoma (early): Simple or extended cholecystectomy with lymphadenectomy first-line depending on tumour depth (often found incidentally after routine cholecystectomy); monitor for recurrence with surveillance imaging; screen for and address risk factors (porcelain gallbladder, large polyps) proactively in at-risk populations.
- Primary sclerosing cholangitis: No proven disease-modifying medical therapy; manage complications (dominant stricture dilatation via ERCP, cholestatic symptom control) and monitor for cholangiocarcinoma and colorectal cancer (annual colonoscopy given strong IBD association) and progression to cirrhosis; liver transplantation for end-stage disease, though recurrence can occur post-transplant.
- Primary biliary cholangitis: Ursodeoxycholic acid first-line, improving biochemical response and slowing progression in most patients; add obeticholic acid or fibrates for inadequate biochemical response; monitor liver biochemistry (alkaline phosphatase response predicts outcome) and screen for associated autoimmune conditions and osteoporosis; pruritus managed with cholestyramine or other antipruritics.
- Autoimmune hepatitis: Corticosteroids (with or without azathioprine) first-line for induction, tapering to the lowest dose maintaining remission with a steroid-sparing agent; monitor liver biochemistry and consider repeat biopsy before stopping treatment given high relapse risk; liver transplantation for acute severe presentation or end-stage disease unresponsive to therapy.
- Non-alcoholic fatty liver disease: Weight loss (7-10% of body weight) and management of metabolic risk factors first-line, which improves steatohepatitis and fibrosis; pioglitazone or GLP-1 agonists/newer agents for biopsy-proven NASH with fibrosis; monitor liver fibrosis non-invasively (elastography) and cardiovascular risk, the leading cause of mortality in this population.
- Alcoholic hepatitis (severe): Corticosteroids (with Lille score reassessment at day 7 to guide continuation) first-line for severe disease (Maddrey score ≥32); alcohol abstinence support is essential alongside; monitor for infection before and during steroid therapy, and renal function given hepatorenal syndrome risk; nutritional support with adequate calorie/protein intake improves outcomes.
- Wilson's disease (hepatic presentation): Chelation therapy (penicillamine or trientine) first-line, or zinc for pre-symptomatic/maintenance therapy; liver transplantation for acute liver failure or decompensated cirrhosis unresponsive to medical therapy; monitor copper studies (24h urinary copper, caeruloplasmin) and liver function; screen siblings given autosomal recessive inheritance.
- Acute liver failure: Supportive ICU-level care addressing coagulopathy, encephalopathy, and cerebral oedema first-line, with N-acetylcysteine for paracetamol-induced cases regardless of cause suspected; urgent liver transplantation assessment using validated prognostic criteria (King's College criteria); monitor ammonia, coagulation, and neurological status closely given rapid deterioration risk.
- Budd-Chiari syndrome: Anticoagulation first-line once diagnosed, escalating to angioplasty/stenting or TIPS for symptomatic outflow obstruction, and liver transplantation for fulminant or decompensated cirrhotic disease; monitor for an underlying prothrombotic disorder (myeloproliferative neoplasm is common) requiring separate long-term management; screen for JAK2 mutation.
- Short bowel syndrome: Nutritional optimisation (enteral where possible, parenteral nutrition if inadequate absorption) first-line, with antidiarrhoeal/antisecretory agents to reduce output; teduglutide (GLP-2 analogue) for those dependent on parenteral nutrition to promote adaptation; monitor fluid/electrolyte balance and for parenteral nutrition-associated liver disease; intestinal transplantation reserved for irreversible intestinal failure with life-threatening complications.
- Familial adenomatous polyposis: Prophylactic colectomy (typically in late teens/early twenties) is definitive given near-universal cancer risk if untreated; regular endoscopic surveillance (upper and lower GI) before and after surgery for polyp progression and duodenal/ampullary polyps; genetic testing and counselling for at-risk relatives given autosomal dominant inheritance.
- Lynch syndrome (surveillance): Regular colonoscopic surveillance from a young age (typically every 1-2 years) is the mainstay rather than prophylactic surgery; consider risk-reducing hysterectomy/salpingo-oophorectomy after childbearing given endometrial/ovarian cancer risk; genetic testing and cascade testing of relatives given autosomal dominant inheritance; aspirin chemoprevention has evidence for colorectal cancer risk reduction.
- Anal carcinoma: Chemoradiotherapy (Nigro protocol) first-line, achieving good cure rates while preserving sphincter function, with surgery reserved for residual/recurrent disease; monitor treatment response and for late radiation toxicity; HIV-positive patients have higher incidence and should be screened for HPV-related disease.
- Carcinoid tumour (gastrointestinal): Surgical resection first-line for localised disease; somatostatin analogues (octreotide) for symptom control of carcinoid syndrome and disease control in unresectable/metastatic disease; monitor 5-HIAA levels and for carcinoid heart disease with echocardiography; avoid precipitants of carcinoid crisis (anaesthesia, tumour manipulation) without pre-treatment octreotide.
- Coeliac crisis: IV fluid and electrolyte resuscitation plus corticosteroids first-line for this rare severe presentation of coeliac disease with profound diarrhoea/malabsorption; strict gluten-free diet established once stabilised; monitor electrolytes closely given risk of refeeding syndrome and severe dehydration; distinguish from other causes of acute severe diarrhoea.
- Whipple's disease: Prolonged antibiotic therapy (initial IV ceftriaxone/penicillin followed by extended oral co-trimoxazole, typically 1 year) first-line given high relapse risk with shorter courses; monitor for neurological involvement, which may require CNS-penetrating regimens and closer surveillance; relapse can present atypically, requiring a high index of suspicion.
- Protein-losing enteropathy: Treat the underlying cause (cardiac, inflammatory, lymphatic) first-line, as this determines definitive management; supportive nutritional support (high-protein diet, medium-chain triglycerides for lymphatic causes) alongside; monitor serum albumin and alpha-1-antitrypsin clearance to track response; diuretics for associated oedema.
- Intestinal tuberculosis: Standard anti-tubercular therapy (4-drug regimen) first-line, generally for 6 months (may be extended); surgery reserved for complications (obstruction, perforation, bleeding) unresponsive to medical therapy; monitor clinical/radiological response; distinguishing from Crohn's disease can be difficult and is critical since immunosuppression would worsen TB.
Endocrine & Metabolic
- Type 2 diabetes mellitus: Metformin first-line alongside lifestyle modification, adding SGLT2 inhibitor or GLP-1 agonist early for those with established cardiovascular/renal disease or obesity regardless of glycaemic control; escalate to insulin for symptomatic hyperglycaemia or inadequate control on combination oral therapy; monitor HbA1c 3-6 monthly, renal function, and annual screening for retinopathy/nephropathy/neuropathy; adjust metformin dose or hold in significant renal impairment or acute illness risking lactic acidosis.
- Metabolic syndrome and obesity: Lifestyle modification (diet, exercise, weight loss) first-line targeting each component (glycaemia, lipids, blood pressure, waist circumference); add pharmacotherapy (GLP-1 agonists) or bariatric surgery for inadequate response with significant obesity; monitor components individually with periodic reassessment of cardiovascular risk; address components together rather than in isolation, as they synergistically increase cardiovascular risk.
- Dyslipidemia: Statin therapy first-line, intensity guided by cardiovascular risk category; add ezetimibe or PCSK9 inhibitor for inadequate LDL reduction on maximally tolerated statin, particularly in very high-risk patients; monitor lipid panel and liver function on initiation/uptitration; check creatine kinase only if myalgia occurs, as routine monitoring is not required, and use caution combining statins with fibrates given myopathy risk.
- Cushing syndrome: Surgical resection of the causative source (pituitary adenoma, adrenal tumour, or ectopic ACTH source) is first-line definitive treatment; medical therapy (ketoconazole, metyrapone, or osilodrostat) used to control hypercortisolism pre-operatively or when surgery is not curative/feasible; monitor cortisol levels post-operatively for adrenal insufficiency requiring glucocorticoid replacement; screen for and manage cardiovascular risk factors, which remain elevated even after biochemical cure.
- Hyperparathyroidism: Parathyroidectomy is definitive first-line for symptomatic primary hyperparathyroidism or those meeting surgical criteria (marked hypercalcaemia, renal/bone involvement, age <50); cinacalcet or bisphosphonates for those unfit for or declining surgery; monitor calcium, PTH, and bone density; localise the abnormal gland pre-operatively with sestamibi scan/ultrasound to guide minimally invasive surgery.
- Type 1 diabetes mellitus: Basal-bolus insulin regimen (or insulin pump) first-line with carbohydrate counting education; escalate to continuous glucose monitoring and automated insulin delivery systems for suboptimal control or recurrent hypoglycaemia; monitor HbA1c, time-in-range on CGM, and annual screening for microvascular complications and autoimmune comorbidities (thyroid, coeliac disease); educate on sick-day rules to prevent DKA during intercurrent illness.
- Diabetic ketoacidosis: IV fluid resuscitation, fixed-rate IV insulin infusion, and potassium replacement first-line, following a structured protocol; do not stop insulin once glucose normalises, but add dextrose-containing fluids instead to allow continued ketone clearance; monitor capillary ketones/blood glucose hourly and venous bicarbonate/pH regularly until resolution; identify and treat the precipitant (infection, insulin omission, new diagnosis) concurrently.
- Hyperosmolar hyperglycaemic state: IV fluid resuscitation first-line with cautious, slower correction than DKA given very high osmolality and older, often frailer patient population; insulin started at lower rates or delayed until fluids alone have begun lowering glucose, to avoid precipitous osmotic shifts; monitor osmolality, glucose, and neurological status closely, and consider prophylactic anticoagulation given high VTE risk from hyperviscosity; identify and treat the precipitant, often infection or a new cardiovascular event.
- Hypoglycaemia (severe): IV dextrose or IM glucagon first-line for severe hypoglycaemia with impaired consciousness where oral intake is unsafe; oral fast-acting carbohydrate for conscious patients able to swallow; monitor capillary glucose every 15 minutes until stable and recurrence risk (particularly with long-acting insulin or sulfonylureas, which may need prolonged observation/dextrose infusion); review and adjust the precipitating medication regimen before discharge.
- Primary hypothyroidism: Levothyroxine replacement first-line, started at full dose in younger healthy patients but low-dose with gradual titration in the elderly or those with cardiac disease given risk of precipitating angina/arrhythmia; monitor TSH 6-8 weeks after dose changes, then annually once stable; increase dose in pregnancy (typically ~30% increment) as early as pregnancy is confirmed, and separate dosing from calcium/iron supplements which impair absorption.
- Hyperthyroidism (Graves' disease): Antithyroid drugs (carbimazole/methimazole, or propylthiouracil in first trimester pregnancy) first-line, with beta-blockers for symptomatic control; escalate to radioactive iodine or thyroidectomy for relapse after drug withdrawal or patient preference; monitor thyroid function 4-6 weekly during titration and full blood count for agranulocytosis (advise urgent review for sore throat/fever); avoid radioactive iodine in active moderate-severe Graves' orbitopathy, which it can worsen.
- Thyroid storm: High-dose antithyroid drugs, iodine solution (given at least an hour after antithyroid drugs to avoid fuelling synthesis), beta-blockade, and corticosteroids together first-line, alongside aggressive supportive care (cooling, fluids); treat the precipitant (infection, surgery, non-compliance); monitor cardiac rhythm, temperature, and mental status continuously in an ICU setting; this is a medical emergency with significant mortality if treatment is delayed.
- Myxoedema coma: IV levothyroxine (with or without liothyronine) plus stress-dose IV hydrocortisone first-line, as unrecognised coexisting adrenal insufficiency can be unmasked by thyroid hormone replacement; supportive care for hypothermia, hypoventilation, and hypotension, often requiring ICU admission; monitor mental status, temperature, and cardiac rhythm closely; identify and treat the precipitant (infection, cold exposure, sedative drugs) concurrently.
- Thyroid nodule (suspicious): Fine-needle aspiration cytology first-line for nodules with suspicious ultrasound features or size criteria; surgical excision (lobectomy or total thyroidectomy) for indeterminate/malignant cytology or compressive symptoms; monitor benign nodules with periodic ultrasound; molecular testing can help risk-stratify indeterminate cytology results and avoid unnecessary surgery in select cases.
- Addison's disease (adrenal insufficiency): Glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement first-line, with patient education on sick-day dose doubling/tripling during illness; monitor for adequacy of replacement clinically (weight, blood pressure, electrolytes) rather than by cortisol level; issue a steroid emergency card/bracelet and IM hydrocortisone kit for emergency self-administration; increase doses substantially for surgery or severe illness to prevent adrenal crisis.
- Adrenal crisis: Immediate IV hydrocortisone and aggressive IV fluid resuscitation first-line, given without waiting for confirmatory cortisol results if clinical suspicion is high, as delay is life-threatening; identify and treat the precipitant (infection, missed doses, surgery); monitor blood pressure, electrolytes (hyponatraemia/hyperkalaemia), and glucose closely; transition to oral maintenance replacement once stable, with mineralocorticoid resumed once hydrocortisone dose is tapered toward physiological levels.
- Primary hyperaldosteronism: Mineralocorticoid receptor antagonist (spironolactone/eplerenone) first-line for bilateral adrenal hyperplasia or those unfit for/declining surgery; adrenalectomy is first-line and potentially curative for unilateral aldosterone-producing adenoma confirmed by adrenal vein sampling; monitor blood pressure and potassium; screen all resistant hypertension and hypertension with hypokalaemia for this treatable secondary cause via aldosterone-renin ratio.
- Phaeochromocytoma: Alpha-blockade (phenoxybenzamine/doxazosin) first-line for at least 1-2 weeks pre-operatively, with beta-blockade added only after adequate alpha-blockade to avoid unopposed alpha-mediated hypertensive crisis; surgical resection is definitive once adequately blocked; monitor blood pressure and heart rate closely during blockade titration and peri-operatively; genetic testing is recommended given significant association with hereditary syndromes (MEN2, VHL, SDH mutations).
- Prolactinoma: Dopamine agonist (cabergoline first-line, preferred over bromocriptine for efficacy and tolerability) normalises prolactin and shrinks most tumours, avoiding surgery in the majority; surgery reserved for resistant/intolerant cases or apoplexy; monitor prolactin levels and visual fields/MRI for macroadenomas; dopamine agonists are generally continued safely through pregnancy if needed for tumour control, particularly with macroadenomas.
- Acromegaly: Trans-sphenoidal surgery is first-line definitive treatment for resectable pituitary somatotroph adenomas; medical therapy (somatostatin analogues, pegvisomant, or cabergoline) for residual/recurrent disease or those unfit for surgery; monitor IGF-1 and growth hormone suppression on OGTT to assess biochemical control; screen for and manage cardiovascular, sleep apnoea, and colonic polyp complications given increased risk.
- Diabetes insipidus (central): Desmopressin (DDAVP) replacement first-line, titrated to urine output and thirst; monitor serum sodium closely, particularly on initiation, given risk of dilutional hyponatraemia if fluid intake is not moderated; identify the underlying cause (pituitary surgery, trauma, infiltrative disease) as it may guide additional management; distinguish from nephrogenic DI via desmopressin response testing, as management differs substantially.
- SIADH (hyponatraemia): Fluid restriction first-line for chronic, asymptomatic SIADH-related hyponatraemia; add a vaptan (tolvaptan) or demeclocycline for refractory cases; use hypertonic saline for severe symptomatic hyponatraemia instead; monitor sodium correction rate closely (no faster than 8-10 mmol/L/24h) to avoid osmotic demyelination; identify and treat the underlying cause (malignancy, CNS pathology, drugs, pulmonary disease).
- Osteoporosis: Oral bisphosphonate first-line alongside calcium/vitamin D optimisation and weight-bearing exercise; escalate to denosumab, or anabolic agents (teriparatide/romosozumab) for severe/high-risk fracture or bisphosphonate-refractory disease; monitor bone density (DEXA) every 1-2 years and renal function before bisphosphonate dosing; consider drug holidays after prolonged bisphosphonate use to reduce atypical femoral fracture/osteonecrosis of the jaw risk.
- Paget's disease of bone: Bisphosphonate therapy first-line for symptomatic disease or disease at high-risk sites (weight-bearing bones, skull base); monitor alkaline phosphatase to guide treatment response and need for retreatment; escalate to surgery for pathological fracture, severe deformity, or nerve compression; screen for rare malignant transformation (osteosarcoma) if new bone pain or rapidly rising alkaline phosphatase occurs.
- Hypercalcaemia of malignancy: IV fluid resuscitation first-line followed by IV bisphosphonate (zoledronic acid) for sustained calcium lowering; denosumab as an alternative in renal impairment where bisphosphonates are contraindicated; monitor calcium, renal function, and for bisphosphonate-related hypocalcaemia/renal toxicity; calcitonin provides rapid but short-lived effect useful as a bridge while awaiting bisphosphonate onset.
- Hypocalcaemia (symptomatic): IV calcium gluconate first-line for symptomatic/severe hypocalcaemia (tetany, seizures, QT prolongation), followed by oral calcium and vitamin D/calcitriol; monitor calcium, magnesium (correct concurrent hypomagnesaemia, which impairs PTH response), and ECG during acute correction; identify the underlying cause (post-surgical hypoparathyroidism, vitamin D deficiency) to guide longer-term therapy.
- Familial hypercholesterolaemia: High-intensity statin first-line, started early given lifelong LDL exposure; add ezetimibe or PCSK9 inhibitor for inadequate LDL reduction, given very high cardiovascular risk; monitor LDL levels aggressively toward target and screen first-degree relatives (cascade testing) given autosomal dominant inheritance; consider LDL apheresis for homozygous or severe treatment-refractory disease.
- Type 2 diabetes with established cardiovascular disease: SGLT2 inhibitor or GLP-1 receptor agonist first-line regardless of HbA1c, given proven cardiovascular benefit in this population, alongside metformin and standard secondary prevention (statin, antiplatelet, blood pressure control); monitor HbA1c, renal function, and volume status on SGLT2 inhibitors; avoid agents with neutral/adverse cardiovascular signal as second-line choices in this high-risk group.
- Diabetic peripheral neuropathy: Optimise glycaemic control first-line to slow progression, plus a first-line neuropathic pain agent (pregabalin, gabapentin, duloxetine, or amitriptyline) for painful symptoms; monitor for progression with regular foot examination given loss of protective sensation risk; screen for foot ulceration risk and provide footwear/education, as neuropathy is the key driver of diabetic foot complications.
- Diabetic foot ulcer: Offloading, wound debridement, and infection control (targeted antibiotics if infected) first-line, with multidisciplinary diabetic foot team involvement; escalate to vascular assessment/revascularisation if significant peripheral arterial disease coexists, and surgical debridement or amputation for deep infection/osteomyelitis; monitor wound healing, perfusion, and glycaemic control; regular offloading footwear and podiatry follow-up reduce recurrence.
- Charcot foot (neuroarthropathy): Total contact casting and strict offloading first-line during the acute phase to prevent progressive bony destruction and deformity; escalate to surgical correction for severe deformity, instability, or recurrent ulceration once the acute phase resolves; monitor with serial imaging and skin temperature (differential warmth signals ongoing activity); distinguishing acute Charcot from infection/cellulitis is critical as management differs substantially.
- Subacute (de Quervain's) thyroiditis: NSAIDs first-line for mild pain, with corticosteroids for more severe pain or marked thyrotoxic symptoms; beta-blockers for symptomatic thyrotoxic phase (antithyroid drugs are not used as this is not driven by increased synthesis); monitor thyroid function through the classic triphasic course (thyrotoxic, hypothyroid, recovery); most cases resolve spontaneously over weeks to months.
- Hashimoto's thyroiditis: Levothyroxine replacement once overt hypothyroidism develops, following standard hypothyroidism dosing/monitoring principles; observation alone is appropriate for subclinical disease with normal/mildly elevated TSH and no symptoms in most patients; monitor TSH periodically given progression to overt hypothyroidism over time; screen for coexisting autoimmune conditions (coeliac disease, type 1 diabetes, pernicious anaemia).
- Multinodular goitre (toxic): Radioactive iodine or antithyroid drugs first-line for medical control of thyrotoxicosis; surgery (thyroidectomy) for compressive symptoms, suspicious nodules, or patient preference; monitor thyroid function and, for large goitres, airway/oesophageal compression symptoms; radioactive iodine may cause transient worsening of thyrotoxicosis and is used cautiously in significant compressive symptoms.
- Thyroid eye disease (Graves' orbitopathy): Smoking cessation and lubrication/supportive eye care first-line for mild disease; high-dose IV corticosteroids or teprotumumab for moderate-severe active disease; orbital decompression surgery for sight-threatening compressive optic neuropathy; monitor visual acuity, colour vision, and disease activity score; achieve stable euthyroidism, as both hyper- and hypothyroidism can worsen orbitopathy, and avoid radioactive iodine in active moderate-severe disease.
- Medullary thyroid carcinoma: Total thyroidectomy with central neck dissection is first-line, as this tumour does not respond to radioactive iodine (non-follicular cell origin); escalate to tyrosine kinase inhibitors (selpercatinib, vandetanib) for advanced/metastatic disease; monitor serum calcitonin and CEA as tumour markers; screen for MEN2 syndrome and coexisting phaeochromocytoma (which must be excluded/treated before thyroid surgery) given strong genetic association.
- Papillary thyroid carcinoma: Total or partial thyroidectomy first-line depending on tumour size/risk features, with radioactive iodine ablation for higher-risk disease; monitor thyroglobulin (as a tumour marker after total thyroidectomy) and neck ultrasound for recurrence; TSH suppression with levothyroxine is used post-operatively in higher-risk disease to reduce recurrence risk; excellent prognosis overall, allowing more conservative management (lobectomy, active surveillance) in low-risk small tumours.
- Parathyroid carcinoma: En-bloc surgical resection (including ipsilateral thyroid lobe) is first-line, as this rare malignancy is often diagnosed intra-operatively or on suspicion of invasive features; monitor calcium and PTH post-operatively for recurrence; cinacalcet for symptomatic hypercalcaemia in recurrent/metastatic disease where further surgery is not feasible; radiotherapy has a limited role given relative radioresistance.
- Hypoparathyroidism (post-surgical): Oral calcium and active vitamin D (calcitriol) first-line, titrated to maintain calcium in the low-normal range; add recombinant PTH for refractory cases requiring very high calcium/vitamin D doses; monitor calcium, phosphate, and 24-hour urinary calcium (to avoid nephrocalcinosis from over-replacement); most post-surgical cases are transient, resolving within days to weeks, but a minority become permanent.
- Pseudohypoparathyroidism: Calcium and active vitamin D supplementation first-line, similar to hypoparathyroidism, but PTH levels remain elevated due to end-organ resistance rather than deficiency; monitor calcium, phosphate, and PTH; screen for associated features (Albright hereditary osteodystrophy phenotype, other hormone resistance) and for associated skeletal/developmental abnormalities depending on subtype.
- Cushing's disease (pituitary): Trans-sphenoidal pituitary surgery is first-line definitive treatment; medical therapy (ketoconazole, metyrapone, pasireotide) or bilateral adrenalectomy for surgical failure or unfit patients; monitor post-operative cortisol for cure (low/undetectable cortisol indicates biochemical remission requiring glucocorticoid replacement); monitor long-term for recurrence, which can occur years after apparent cure.
- Nelson's syndrome: Trans-sphenoidal surgical resection of the enlarging pituitary tumour is first-line following bilateral adrenalectomy for Cushing's disease; radiotherapy for residual/recurrent tumour; monitor ACTH levels and pituitary imaging regularly after bilateral adrenalectomy to detect early Nelson's syndrome; prophylactic pituitary radiotherapy at the time of adrenalectomy may reduce incidence in high-risk patients.
- Hypopituitarism: Hormone replacement tailored to each deficient axis, with glucocorticoid replacement prioritised first (before thyroxine, to avoid precipitating adrenal crisis by increasing metabolic clearance of cortisol); monitor each axis individually (cortisol, thyroid function, sex hormones, growth hormone as indicated); identify and treat the underlying cause (pituitary tumour, apoplexy, Sheehan syndrome, radiotherapy) and provide a steroid emergency card if glucocorticoid-dependent.
- Sheehan's syndrome: Hormone replacement across affected axes (glucocorticoid, thyroid, and others as needed) first-line, analogous to other causes of hypopituitarism; monitor for evolving deficiencies, which may present acutely (failure to lactate, amenorrhoea) or subtly over years; a history of severe post-partum haemorrhage with subsequent failure to lactate should prompt pituitary function testing.
- Craniopharyngioma: Surgical resection (often with adjuvant radiotherapy for residual/recurrent tumour) is first-line; monitor for panhypopituitarism and diabetes insipidus, both common post-operatively, requiring hormone replacement; monitor visual fields given proximity to the optic chiasm; long-term follow-up for hypothalamic dysfunction (obesity, temperature dysregulation) and tumour recurrence is required, particularly in children.
- Ectopic ACTH syndrome: Treat the underlying malignancy (often small cell lung cancer or carcinoid tumour) first-line where identifiable and resectable; medical cortisol-lowering therapy (ketoconazole, metyrapone, or etomidate in severe acute cases) for rapid control while source is localised or in unresectable disease; monitor cortisol, potassium (severe hypokalaemia common), and glucose; bilateral adrenalectomy considered if the source cannot be found or controlled.
- Insulinoma: Surgical enucleation or resection is first-line and often curative for localised, sporadic insulinoma; diazoxide or somatostatin analogues for symptom control pre-operatively or in unresectable/metastatic disease; monitor for hypoglycaemia with supervised fasting test used diagnostically; screen for MEN1 syndrome, particularly with multifocal or recurrent tumours.
- Glucagonoma: Surgical resection is first-line for localised disease; somatostatin analogues (octreotide) for symptom control (necrolytic migratory erythema, hyperglycaemia) in unresectable/metastatic disease; monitor glucose, weight, and for venous thromboembolism, which occurs at markedly increased frequency in glucagonoma; nutritional support and VTE prophylaxis are important adjuncts given catabolic state.
- MEN 1 syndrome (surveillance/management): Manage each component tumour individually as it arises (parathyroidectomy for hyperparathyroidism, surgery/somatostatin analogues for pancreatic neuroendocrine tumours, trans-sphenoidal surgery for pituitary adenomas); lifelong biochemical and imaging surveillance is essential given near-universal, multifocal, and recurrent tumour development; screen first-degree relatives with genetic testing given autosomal dominant inheritance.
- MEN 2 syndrome: Prophylactic thyroidectomy timed by RET mutation risk category (often in early childhood for highest-risk mutations) is first-line to prevent medullary thyroid carcinoma; screen for and treat phaeochromocytoma before any surgery given risk of intra-operative hypertensive crisis; monitor calcitonin, calcium/PTH (MEN2A), and catecholamines regularly; genetic testing and counselling for at-risk relatives is essential given autosomal dominant inheritance with high penetrance.
- Obesity (class II-III): Structured lifestyle intervention first-line, adding pharmacotherapy (GLP-1/GIP agonists) for inadequate response, particularly with obesity-related comorbidity; bariatric surgery for class III obesity or class II with significant comorbidity refractory to medical therapy; monitor weight trajectory, metabolic comorbidities, and nutritional status post-surgery (vitamin/mineral deficiencies); comprehensive comorbidity screening (sleep apnoea, NAFLD, diabetes) should accompany management.
- Metabolic acidosis due to lactic acidosis: Treat the underlying cause (fluid resuscitation and source control for sepsis/hypoperfusion, stopping metformin in metformin-associated lactic acidosis) first-line rather than bicarbonate alone; escalate to renal replacement therapy for severe refractory acidosis, particularly with metformin accumulation in renal failure; monitor lactate clearance and arterial blood gas trend as markers of response; distinguish type A (hypoperfusion) from type B (drug/metabolic) lactic acidosis as this guides specific treatment.
- Refeeding syndrome (risk): Cautious, gradual reintroduction of nutrition first-line in at-risk patients (prolonged starvation, low BMI, minimal intake >10 days), starting well below full caloric requirement and increasing gradually over days; pre-emptive thiamine and electrolyte (phosphate, potassium, magnesium) supplementation before and during feeding; monitor electrolytes daily for the first week, as refeeding hypophosphataemia can cause cardiac/respiratory failure; identify high-risk patients proactively rather than reacting after electrolyte derangement occurs.
Hematology & Oncology
- Chronic myeloid leukaemia: Tyrosine kinase inhibitor (imatinib first-line, or a second-generation TKI) is first-line and has transformed prognosis; escalate to alternate TKI or allogeneic transplant for resistance/intolerance or progression to accelerated/blast phase; monitor BCR-ABL transcript levels by PCR at defined intervals to assess molecular response; screen for cardiovascular risk before second-generation TKIs given differing toxicity profiles.
- Chronic lymphocytic leukaemia: Observation ('watch and wait') first-line for asymptomatic early-stage disease, as early treatment does not improve survival; targeted therapy (BTK inhibitor or venetoclax-based regimen) for symptomatic/progressive disease, largely replacing chemoimmunotherapy; monitor blood counts, lymph node size, and for Richter transformation (aggressive lymphoma transformation); screen for TP53/17p deletion before treatment selection as it predicts chemoimmunotherapy resistance.
- Tumor lysis syndrome: IV hydration and rasburicase (or allopurinol for lower-risk disease) first-line, started pre-emptively in high-risk malignancies before chemotherapy; escalate to renal replacement therapy for severe refractory hyperkalaemia, hyperphosphataemia, or renal failure; monitor electrolytes, uric acid, and renal function frequently (every 4-6 hours) during the highest-risk period; avoid rasburicase in G6PD deficiency due to haemolysis risk.
- Febrile neutropenia: Empirical broad-spectrum IV antibiotics (anti-pseudomonal beta-lactam) within one hour of presentation is first-line, regardless of identified source; escalate to antifungal cover for persistent fever beyond 4-7 days despite antibiotics; monitor temperature, neutrophil count recovery, and cultures; risk-stratify (e.g. MASCC score) to identify low-risk patients potentially suitable for oral antibiotics/outpatient management.
- Thalassemia minor (trait): No specific treatment is required for thalassaemia trait itself, as it is typically asymptomatic with mild microcytic anaemia; genetic counselling is important, particularly for reproductive planning given risk of thalassaemia major in offspring if both partners carry trait; monitor to distinguish from iron deficiency (normal/high ferritin, disproportionately low MCV for degree of anaemia); avoid inappropriate iron supplementation, which does not help and may cause overload.
- Iron deficiency anaemia: Oral iron replacement first-line, continued for 3 months after normalisation to replenish stores; IV iron for intolerance, malabsorption, or ongoing significant losses; monitor haemoglobin response at 2-4 weeks and ferritin to confirm repletion; investigate the underlying cause (particularly GI blood loss) in adults, especially post-menopausal women and men, given risk of underlying malignancy.
- Megaloblastic anaemia (B12 deficiency): IM/high-dose oral B12 replacement first-line, with more frequent initial dosing for neurological involvement; monitor haemoglobin, MCV, and neurological symptoms, which may take longer to resolve than haematological parameters; check for pernicious anaemia (intrinsic factor antibodies) as the underlying cause requires lifelong replacement; replace B12 before folate if both are deficient, as folate alone can precipitate subacute combined degeneration.
- Folate deficiency anaemia: Oral folate replacement first-line; always check and correct B12 status first or concurrently, as isolated folate replacement can mask B12 deficiency and precipitate neurological damage; monitor haemoglobin response over several weeks; identify the underlying cause (poor intake, malabsorption, increased demand in pregnancy/haemolysis) as it guides duration of therapy.
- Aplastic anaemia (severe): Allogeneic stem cell transplant is first-line curative therapy for younger patients with a matched donor; immunosuppressive therapy (antithymocyte globulin plus ciclosporin) for those unsuitable for transplant; monitor blood counts closely and provide supportive transfusion/infection prophylaxis while awaiting response; eltrombopag may be added to immunosuppression to improve response rates.
- Sickle cell crisis (vaso-occlusive): IV fluids, opioid analgesia, and oxygen (if hypoxic) first-line, with early aggressive pain control; escalate to exchange transfusion for acute chest syndrome, stroke, or multi-organ failure; monitor oxygen saturation, pain scores, and for evolving acute chest syndrome (new infiltrate plus respiratory symptoms), a leading cause of death; hydroxyurea reduces crisis frequency long-term and should be reviewed as maintenance therapy after recovery.
- Thalassaemia major: Regular lifelong blood transfusion first-line to maintain haemoglobin and suppress ineffective erythropoiesis, combined with iron chelation therapy to prevent transfusional iron overload; allogeneic stem cell transplant is curative in eligible children with a matched donor; monitor ferritin/cardiac and hepatic iron (MRI T2*) and endocrine function (growth, pubertal development) given chelation-preventable organ damage from iron overload.
- Haemophilia A (bleeding episode): Factor VIII replacement first-line, dosed according to bleed severity and target site; escalate to higher-dose/continuous infusion for major bleeds or surgery; monitor factor VIII levels and for inhibitor development (reduced response to replacement) which requires bypassing agents (activated factor VII or FEIBA); prophylactic factor replacement or emicizumab reduces long-term joint damage in severe disease.
- Immune thrombocytopenic purpura: Corticosteroids first-line for significant bleeding/very low platelet count, with IVIG for rapid platelet rise when urgent (active bleeding, pre-procedure); escalate to thrombopoietin receptor agonists, rituximab, or splenectomy for chronic/refractory disease; monitor platelet count response; avoid platelet transfusion alone except for life-threatening bleeding, as transfused platelets are rapidly destroyed by the same antibody process.
- Thrombotic thrombocytopenic purpura: Urgent plasma exchange plus corticosteroids first-line, started on clinical suspicion without waiting for ADAMTS13 confirmation given rapid mortality if untreated; add caplacizumab and rituximab for refractory/relapsing disease; monitor platelet count, LDH, and schistocytes daily to assess response; avoid platelet transfusion unless life-threatening bleeding, as it can worsen microvascular thrombosis.
- Disseminated intravascular coagulation: Treat the underlying cause, with blood product support (FFP, platelets, cryoprecipitate) guided by bleeding and labs.
- Deep venous thrombosis with malignancy: Low-molecular-weight heparin or a DOAC (in appropriate cancer types without significant GI mucosal involvement) first-line, generally continued long-term/indefinitely while active malignancy persists given high recurrence risk; monitor for bleeding, particularly with DOACs in GI malignancies; reassess anticoagulation choice if the patient develops significant renal impairment or is undergoing procedures requiring interruption.
- Hodgkin lymphoma: Combination chemotherapy (ABVD-based) first-line, with radiotherapy added for early-stage/bulky disease; escalate to salvage chemotherapy and autologous stem cell transplant for relapsed/refractory disease; monitor with interim PET-CT to guide treatment intensity/response-adapted therapy; screen for and monitor late treatment effects (secondary malignancy, cardiac/pulmonary toxicity) given generally excellent long-term survival and long follow-up horizon.
- Non-Hodgkin lymphoma (diffuse large B-cell): R-CHOP (rituximab plus combination chemotherapy) first-line with curative intent; escalate to CAR-T cell therapy or autologous transplant for relapsed/refractory disease; monitor with interim and end-of-treatment PET-CT; screen for tumour lysis syndrome risk before first cycle given rapid tumour bulk reduction, and for CNS relapse risk factors guiding prophylactic intrathecal therapy.
- Multiple myeloma: Combination therapy (proteasome inhibitor, immunomodulatory drug, and corticosteroid) first-line, followed by autologous stem cell transplant in eligible patients; escalate to CAR-T cell therapy or bispecific antibodies for relapsed/refractory disease; monitor serum free light chains/paraprotein, renal function, and calcium; bone-protective therapy (bisphosphonate/denosumab) is given alongside systemic therapy given high skeletal complication risk.
- Acute myeloid leukaemia: Intensive induction chemotherapy, with allogeneic transplant for high-risk disease.
- Acute lymphoblastic leukaemia: Risk-stratified multi-phase chemotherapy with CNS-directed prophylaxis.
- Polycythaemia vera: Low-dose aspirin and therapeutic phlebotomy first-line to target haematocrit below threshold, reducing thrombotic risk; add cytoreductive therapy (hydroxyurea, or ruxolitinib for resistant/intolerant disease) for high-risk patients (age >60, prior thrombosis); monitor haematocrit, platelet count, and for progression to myelofibrosis or acute leukaemia; JAK2 mutation testing confirms diagnosis and does not typically change first-line management.
- Essential thrombocythaemia: Low-dose aspirin first-line for low-risk disease; add cytoreductive therapy (hydroxyurea, or anagrelide as an alternative) for high-risk patients (age >60, prior thrombosis, very high platelet count); monitor platelet count and for thrombotic/haemorrhagic complications (acquired von Willebrand syndrome can occur at very high platelet counts, paradoxically increasing bleeding risk); avoid aspirin alone in this scenario given bleeding risk.
- Myelodysplastic syndrome: Supportive care (transfusion support, growth factors) first-line for lower-risk disease; hypomethylating agents (azacitidine) for higher-risk disease, with allogeneic transplant considered in eligible fit patients as the only curative option; monitor blood counts and for progression to AML; risk-stratify using validated scoring systems (e.g. IPSS-R) to guide the intensity of intervention.
- Breast carcinoma (early stage): Surgery (breast-conserving surgery with radiotherapy, or mastectomy) first-line, with adjuvant systemic therapy (endocrine therapy for hormone-receptor-positive, chemotherapy/HER2-targeted therapy as indicated by subtype) tailored to receptor status and risk; monitor with regular clinical and mammographic surveillance post-treatment; genomic assays can help select which hormone-receptor-positive patients benefit from adjuvant chemotherapy versus endocrine therapy alone.
- Lung carcinoma (non-small cell, resectable): Surgical resection is first-line for early-stage disease in fit patients, with adjuvant chemotherapy (+/- immunotherapy) for higher-stage resected disease; stereotactic body radiotherapy is an alternative for those unfit for surgery; monitor with surveillance imaging post-resection; molecular testing (EGFR, ALK, PD-L1) guides targeted/immunotherapy selection even at earlier disease stages increasingly.
- Prostate carcinoma (localised, low-risk): Active surveillance is first-line for low-risk disease, avoiding overtreatment given generally indolent behaviour; radical prostatectomy or radiotherapy for higher-risk localised disease or patient preference against surveillance; monitor PSA and repeat biopsy/MRI at defined intervals during surveillance to detect progression; discuss functional side effects (continence, erectile function) when comparing definitive treatment options.
- Cervical carcinoma (early stage): Radical hysterectomy with lymphadenectomy or definitive chemoradiotherapy first-line depending on stage and fertility wishes; fertility-sparing surgery (radical trachelectomy) is an option in very early disease for appropriate candidates; monitor with regular clinical follow-up and cervical cytology/HPV testing; HPV vaccination and screening are the primary prevention strategies reducing incidence.
- Ovarian carcinoma: Cytoreductive surgery plus platinum-based chemotherapy first-line, with the sequence (upfront surgery vs neoadjuvant chemotherapy then interval surgery) determined by resectability; maintenance PARP inhibitor therapy for BRCA-mutated or homologous-recombination-deficient disease after response to chemotherapy; monitor CA-125 and imaging for response/recurrence; genetic testing (BRCA1/2) should be offered to all patients given both treatment and familial implications.
- Testicular germ cell tumour: Radical orchiectomy is first-line for both diagnosis and initial treatment; adjuvant chemotherapy or surveillance depending on stage and histology (seminoma vs non-seminoma), as both have excellent cure rates even in metastatic disease; monitor tumour markers (AFP, beta-hCG, LDH) and imaging during surveillance/follow-up; sperm banking should be offered before chemotherapy given fertility impact.
- Bladder carcinoma (muscle-invasive): Neoadjuvant chemotherapy followed by radical cystectomy first-line in fit patients; trimodality therapy (maximal TURBT plus chemoradiotherapy) as a bladder-preserving alternative in selected patients; monitor with cystoscopic/imaging surveillance; adjuvant immunotherapy is considered for high-risk residual disease after cystectomy.
- Renal cell carcinoma (localised): Partial or radical nephrectomy is first-line for localised disease, with partial nephrectomy preferred where technically feasible to preserve renal function; active surveillance is an option for small, low-risk tumours in older/comorbid patients; monitor renal function and with surveillance imaging for recurrence; adjuvant immunotherapy is considered in high-risk resected disease.
- Pancreatic adenocarcinoma (resectable): Surgical resection (Whipple procedure for head tumours) first-line in resectable disease, with peri-operative (neoadjuvant and/or adjuvant) chemotherapy given high recurrence risk even after complete resection; monitor CA19-9 and imaging post-resection for recurrence; multidisciplinary review is essential to confirm resectability given proximity to major vessels, and borderline-resectable disease often benefits from neoadjuvant therapy first.
- Anaemia of chronic disease: Treat the underlying inflammatory/chronic disease first-line, as the anaemia typically improves with disease control rather than iron supplementation alone; erythropoiesis-stimulating agents may be used in select settings (chronic kidney disease, chemotherapy-associated anaemia); monitor haemoglobin alongside disease activity markers; distinguish from coexisting iron deficiency (which can occur simultaneously) via ferritin/transferrin saturation, as this changes management.
- Autoimmune haemolytic anaemia: Corticosteroids first-line for warm-antibody AIHA; escalate to rituximab or splenectomy for steroid-refractory/relapsing disease; cold-antibody (cold agglutinin) disease responds poorly to steroids and is instead managed with cold avoidance and rituximab-based therapy; monitor haemoglobin, reticulocyte count, and haemolysis markers (LDH, haptoglobin, bilirubin); identify underlying secondary causes (lymphoproliferative disease, infection, drugs) which may need separate treatment.
- Paroxysmal nocturnal haemoglobinuria: Complement inhibitor therapy (eculizumab/ravulizumab) first-line, which markedly reduces haemolysis and thrombotic risk; allogeneic stem cell transplant is curative and considered for severe/refractory disease or associated bone marrow failure; monitor for breakthrough haemolysis and meningococcal infection risk (vaccination required before starting complement inhibitors given mechanism of action); anticoagulation is considered given high thrombosis risk, particularly at unusual sites.
- Glucose-6-phosphate dehydrogenase deficiency (haemolytic crisis): Removal of the oxidative trigger (drug, infection, fava beans) first-line, alongside supportive care (hydration, transfusion if severe); monitor haemoglobin and for acute kidney injury from haemoglobinuria in severe crises; screen and counsel regarding drugs/foods to avoid long-term (certain antimalarials, sulfonamides, dapsone); neonatal screening is relevant given risk of severe neonatal jaundice/kernicterus.
- Hereditary spherocytosis: Folic acid supplementation and monitoring for mild/moderate disease first-line, as many patients are well-compensated; splenectomy for severe/transfusion-dependent disease, ideally delayed until after age 5-6 in children given post-splenectomy infection risk, with pneumococcal/meningococcal/Hib vaccination beforehand; monitor haemoglobin, reticulocyte count, and gallstone development (chronic haemolysis predisposes to pigment gallstones).
- Von Willebrand disease: Desmopressin (DDAVP) first-line for mild type 1 disease with adequate response on trial dosing, to release stored vWF; von Willebrand factor concentrate for more severe disease, type 2/3, or inadequate DDAVP response, particularly before surgery; monitor factor levels and bleeding time/response to therapy; avoid antiplatelet agents and NSAIDs which worsen bleeding tendency.
- Factor V Leiden thrombophilia (with VTE): Standard anticoagulation for the acute VTE first-line, following usual duration guidelines rather than extending solely because of heterozygous Factor V Leiden, which confers only modest additional risk; extended/indefinite anticoagulation is considered for homozygous mutation, combined thrombophilias, or recurrent unprovoked VTE; monitor for bleeding and reassess ongoing anticoagulation need at defined intervals; routine thrombophilia testing is not required to guide most VTE management decisions.
- Antiphospholipid syndrome (thrombotic): Long-term warfarin (target INR 2-3) first-line, as DOACs show inferior efficacy, particularly in triple-antibody-positive disease; monitor INR closely given labile anticoagulation control in some patients; screen for other autoimmune disease (SLE) and monitor for recurrent thrombosis despite therapeutic anticoagulation, which may require higher-intensity anticoagulation or addition of low-dose aspirin.
- Heparin-induced thrombocytopenia: Immediate cessation of all heparin products first-line, with substitution by a non-heparin anticoagulant (argatroban, fondaparinux, or a DOAC once stable) given ongoing high thrombosis risk despite thrombocytopenia; do not give platelet transfusion for low platelet count alone, as it can worsen thrombosis; monitor platelet count recovery and confirm diagnosis with functional/immunoassay testing; warfarin should not be started until platelets have substantially recovered, given skin necrosis risk.
- Warfarin-associated major bleeding: Immediate cessation of warfarin plus 4-factor prothrombin complex concentrate and IV vitamin K first-line for major/life-threatening bleeding, given rapid reversal compared to FFP alone; monitor INR after reversal and clinical bleeding response; identify and control the bleeding source; reassess the ongoing indication for anticoagulation and timing of resumption once haemostasis is secured.
- Direct oral anticoagulant-associated major bleeding: Specific reversal agent (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors where available) first-line for life-threatening bleeding, with 4-factor prothrombin complex concentrate as an alternative if specific reversal is unavailable; supportive measures (local haemostasis, transfusion) alongside; monitor renal function (affects drug clearance/timing of last dose relevance) and clinical bleeding response; consider activated charcoal if very recent ingestion.
- Splenic rupture (traumatic): Haemodynamically unstable patients require urgent splenectomy or splenic artery embolisation first-line; stable patients with lower-grade injury may be managed with non-operative observation (serial haemoglobin, imaging) in a monitored setting; monitor haemodynamics and haemoglobin closely, as delayed rupture/bleeding can occur; vaccinate against encapsulated organisms if splenectomy is performed, given post-splenectomy sepsis risk.
- Hypersplenism: Treat the underlying cause (e.g. portal hypertension, haematological malignancy) first-line rather than the splenomegaly itself where possible; splenectomy reserved for severe symptomatic cytopenias or massive symptomatic splenomegaly refractory to treating the cause; monitor blood counts and for complications of the underlying disease; vaccinate against encapsulated organisms before elective splenectomy.
- Waldenström macroglobulinaemia: Observation for asymptomatic disease first-line, as early treatment does not improve survival; targeted therapy (BTK inhibitor-based regimen) for symptomatic disease (hyperviscosity, cytopenias, organomegaly); plasmapheresis for acute hyperviscosity syndrome as an urgent bridging measure before systemic therapy takes effect; monitor IgM paraprotein level and blood viscosity.
- Hairy cell leukaemia: Purine analogue (cladribine) is first-line, achieving durable remission in most patients with a single course; escalate to rituximab or targeted therapy (BRAF inhibitor, given near-universal BRAF V600E mutation) for relapsed/refractory disease; monitor blood counts for recovery and relapse; infection risk is heightened both from the disease (monocytopenia) and treatment-related immunosuppression.
- Chronic myelomonocytic leukaemia: Supportive care and hydroxyurea for cytoreduction in proliferative disease first-line; hypomethylating agents for higher-risk disease, with allogeneic transplant considered in eligible fit patients as the only curative option; monitor blood counts and for transformation to AML; this overlap myelodysplastic/myeloproliferative neoplasm has variable behaviour requiring individualised risk stratification.
- Langerhans cell histiocytosis: Observation or local therapy (curettage, low-dose radiotherapy) first-line for single-system, single-site bone disease; systemic chemotherapy for multisystem or high-risk organ involvement; monitor for diabetes insipidus (pituitary involvement) and organ dysfunction; long-term surveillance is needed given risk of late reactivation and neurodegenerative complications.
- Amyloidosis (AL, systemic): Chemotherapy targeting the underlying clonal plasma cell population (bortezomib-based regimen) first-line, often followed by autologous stem cell transplant in eligible patients; monitor free light chains and organ-specific markers (cardiac biomarkers, proteinuria) to assess haematological and organ response; cardiac involvement drives prognosis and requires careful assessment before intensive therapy given risk of decompensation.
- Graft-versus-host disease (acute): Systemic corticosteroids first-line for grade II or higher acute GVHD; escalate to second-line agents (ruxolitinib) for steroid-refractory disease; monitor organ-specific staging (skin, gut, liver) to guide treatment intensity; balance immunosuppression against infection risk and relapse of the underlying malignancy, given the beneficial graft-versus-leukaemia effect that accompanies mild GVHD.
- Tumour lysis syndrome (prevention): Pre-emptive IV hydration and prophylactic allopurinol (or rasburicase for high-risk disease) first-line, started before initiating chemotherapy in at-risk malignancies (high-bulk, rapidly proliferating tumours); monitor electrolytes and renal function closely during the highest-risk 24-72 hour window after treatment initiation; risk-stratify by tumour type/bulk and baseline renal function to determine prophylaxis intensity.
- Febrile neutropenia (low-risk): Oral broad-spectrum antibiotics (e.g. ciprofloxacin plus amoxicillin-clavulanate) with outpatient management may be appropriate first-line for carefully selected low-risk patients (MASCC score-defined) with reliable follow-up; monitor closely for clinical deterioration requiring admission; ensure clear safety-netting and rapid access back to care, as risk stratification tools are imperfect and reassessment is essential.
- Cancer-associated venous thromboembolism: Low-molecular-weight heparin or an appropriate DOAC first-line, generally continued long-term while active malignancy persists given high recurrence risk off anticoagulation; monitor for bleeding, particularly with DOACs in GI/genitourinary malignancies; reassess choice and duration periodically, and consider IVC filter only for absolute anticoagulation contraindication with acute proximal DVT/PE.
- Superior vena cava obstruction (haematological malignancy): Urgent chemotherapy/radiotherapy targeting the underlying lymphoma is first-line, as haematological malignancies are typically highly chemo/radiosensitive, obviating need for stenting in most cases; endovascular stenting for rapid symptom relief in severe/threatening airway compromise while awaiting treatment response; monitor airway and neurological status closely; tissue diagnosis should be obtained urgently but should not unduly delay treatment in life-threatening presentations.
- Malignant pleural effusion: Therapeutic thoracentesis first-line for symptom relief and diagnosis; indwelling pleural catheter or talc pleurodesis for recurrent effusions depending on expected survival and lung re-expansion (trapped lung favours IPC); monitor for re-accumulation and treat the underlying malignancy systemically where feasible; assess for trapped lung before committing to pleurodesis given lower success if the lung cannot fully re-expand.
- Malignant ascites: Therapeutic paracentesis first-line for symptomatic relief; diuretics may help in ascites with a significant portal hypertensive component; peritoneovenous shunt or catheter drainage for recurrent, refractory ascites in appropriate candidates; monitor electrolytes and renal function, particularly with large-volume paracentesis or diuretic use; treat the underlying malignancy systemically where feasible.
- Brain metastases (multiple): Stereotactic radiosurgery or whole-brain radiotherapy first-line depending on number/size of lesions and systemic disease control, alongside corticosteroids for peritumoural oedema/mass effect; targeted/systemic therapy for the primary tumour where CNS-penetrant options exist; monitor neurological status and repeat imaging for response/progression; anticonvulsants are used only if seizures have occurred, not as routine prophylaxis.
- Bone marrow failure (post-chemotherapy): Supportive care (transfusion support, growth factors, infection prophylaxis) first-line while awaiting marrow recovery, which is expected with most standard chemotherapy regimens; monitor blood counts closely for recovery trajectory and evolving cytopenia patterns; investigate for secondary myelodysplasia/leukaemia if recovery is delayed or atypical, particularly after certain chemotherapy classes (alkylating agents, topoisomerase inhibitors).
- Hepatoblastoma (paediatric): Surgical resection combined with chemotherapy (neoadjuvant to shrink tumour, or adjuvant post-resection) first-line, with excellent cure rates in localised disease; liver transplantation for unresectable disease confined to the liver; monitor alpha-fetoprotein as a sensitive tumour marker for response and recurrence; multidisciplinary paediatric oncology input is essential given the rarity of this tumour.
- Wilms tumour (nephroblastoma): Nephrectomy combined with chemotherapy (timing varies by protocol/region, either upfront surgery or neoadjuvant chemotherapy first) is first-line, with excellent overall cure rates; radiotherapy added for higher-stage/unfavourable histology disease; monitor with imaging surveillance for recurrence and screen contralateral kidney for bilateral disease; genetic/syndromic association (WAGR, Beckwith-Wiedemann) should prompt broader surveillance.
- Neuroblastoma (paediatric): Risk-stratified therapy (surgery alone for low-risk, combination chemotherapy/surgery/radiotherapy plus immunotherapy for high-risk disease) is first-line, with treatment intensity guided by age, stage, and biological markers (MYCN amplification); monitor urinary catecholamine metabolites and imaging for response; high-risk disease requires intensive multimodal therapy including autologous stem cell transplant and anti-GD2 immunotherapy.
- Retinoblastoma: Eye-preserving therapy (intra-arterial/intravitreal chemotherapy, focal laser/cryotherapy) is first-line where feasible to preserve vision and the eye; enucleation for advanced intraocular disease or when eye-preserving therapy fails; monitor with regular examination under anaesthesia during active treatment; genetic testing and counselling are important given hereditary forms carrying risk of bilateral disease and secondary malignancy.
- Gastrointestinal stromal tumour (GIST): Surgical resection is first-line for localised, resectable disease; tyrosine kinase inhibitor (imatinib) as neoadjuvant/adjuvant therapy for high-risk resected disease or as primary therapy for unresectable/metastatic disease, given characteristic KIT/PDGFRA mutation sensitivity; monitor with imaging response assessment; mutation testing guides choice of TKI, as some genotypes (e.g. PDGFRA D842V) are imatinib-resistant.
- Merkel cell carcinoma: Wide local excision with sentinel lymph node biopsy is first-line for localised disease, given high metastatic potential even in small tumours; adjuvant radiotherapy for high-risk features; immunotherapy (checkpoint inhibitor) for advanced/metastatic disease, given notable responsiveness; monitor closely for recurrence given aggressive behaviour, and consider immunosuppression status as a risk factor requiring closer surveillance.
Neurology
- Transient ischemic attack: Urgent risk stratification (ABCD2 score) and dual antiplatelet therapy (aspirin plus clopidogrel for 21 days) first-line for high-risk TIA, followed by long-term single antiplatelet and statin; escalate to carotid endarterectomy/stenting for significant symptomatic carotid stenosis, ideally within 2 weeks; monitor for recurrent events and complete rapid vascular imaging (carotid Doppler/CT angiogram) and cardiac rhythm monitoring for AF; treat as a medical emergency given high early stroke risk.
- Tension-type headache: Simple analgesia (paracetamol/NSAIDs) first-line for episodic attacks, limited to avoid medication overuse; add amitriptyline for chronic/frequent tension-type headache prophylaxis; monitor headache frequency/analgesic use with a headache diary; address contributing factors (stress, poor sleep, posture) as part of a non-pharmacological approach.
- Cerebral palsy: Multidisciplinary management (physiotherapy, occupational therapy, speech therapy) first-line focused on function and development; add botulinum toxin injections or oral antispasmodics for spasticity, with selective dorsal rhizotomy or intrathecal baclofen for severe refractory spasticity; monitor growth, hip surveillance (risk of dislocation), and seizure control where epilepsy coexists; early intervention improves functional outcomes.
- Focal epilepsy: A single first-line anti-seizure medication appropriate to focal epilepsy (e.g. lamotrigine, levetiracetam, carbamazepine) is started after a second unprovoked seizure (or after the first in high-recurrence-risk cases); escalate to combination therapy or epilepsy surgery evaluation for drug-resistant disease (failure of two appropriate drugs); monitor seizure frequency, drug levels/side effects, and adherence; MRI is required to exclude a structural lesion amenable to surgical cure.
- Dementia with Lewy bodies: Cholinesterase inhibitors first-line, often with a good response given prominent cholinergic deficit; avoid antipsychotics where possible given marked neuroleptic sensitivity risking severe, sometimes fatal reactions; monitor cognition, hallucinations, and parkinsonism; manage fluctuating cognition, visual hallucinations, and REM sleep behaviour disorder as core features distinguishing it from Alzheimer's disease.
- Acute ischaemic stroke (within window): IV thrombolysis (alteplase/tenecteplase) within the licensed time window first-line, with mechanical thrombectomy added for large vessel occlusion within an extended window based on perfusion imaging; monitor neurological status (NIHSS), blood pressure (kept below thrombolysis thresholds), and for haemorrhagic transformation with repeat imaging; door-to-needle time targets drive protocolised rapid assessment.
- Acute ischaemic stroke (outside window): Aspirin (started within 24-48 hours) first-line as thrombolysis is no longer an option; mechanical thrombectomy may still be appropriate for large vessel occlusion with favourable perfusion imaging beyond standard windows; monitor for progression/complications and initiate secondary prevention (antiplatelet, statin, blood pressure control) alongside early rehabilitation; investigate stroke aetiology (cardioembolic, large/small vessel) to guide long-term prevention.
- Intracerebral haemorrhage: Blood pressure lowering (target systolic <140mmHg acutely) and reversal of any anticoagulation first-line; escalate to neurosurgical evacuation for select cases (cerebellar haemorrhage with deterioration, large lobar haematoma with mass effect); monitor neurological status and repeat imaging for haematoma expansion; avoid routine surgery for most supratentorial haemorrhages, where evidence for benefit is limited outside specific indications.
- Subarachnoid haemorrhage (aneurysmal): Urgent aneurysm securing (endovascular coiling preferred where feasible, or surgical clipping) first-line to prevent rebleeding; nimodipine is given routinely to reduce vasospasm-related delayed cerebral ischaemia; monitor for vasospasm (transcranial Doppler, clinical deterioration) typically days 4-14, hydrocephalus, and hyponatraemia (cerebral salt wasting or SIADH); external ventricular drain for acute hydrocephalus.
- Status epilepticus: IV benzodiazepine first-line, followed promptly by a second-line IV anti-seizure medication (levetiracetam, valproate, or phenytoin) if seizures continue; escalate to anaesthetic agents and intubation for refractory status epilepticus unresponsive to first- and second-line therapy; monitor continuous EEG in refractory/super-refractory cases and treat the underlying cause (electrolytes, infection, non-adherence); avoid delay between treatment steps, as prolonged status worsens outcome.
- Generalised tonic-clonic epilepsy: Sodium valproate is historically first-line but is avoided in women of childbearing potential given teratogenicity, with lamotrigine or levetiracetam preferred instead in this group; monitor seizure frequency and drug levels/side effects; screen for and counsel on pregnancy planning in women of reproductive age given the significant teratogenic risk of several anti-seizure medications; avoid abrupt medication withdrawal, which risks rebound seizures/status epilepticus.
- Migraine (acute attack): Triptan plus NSAID first-line for moderate-severe attacks, taken early in the attack for best efficacy; escalate to prophylactic therapy (beta-blocker, topiramate, or CGRP monoclonal antibody) for frequent/disabling attacks; monitor attack frequency and medication use, screening for medication overuse headache; avoid triptans in significant cardiovascular/cerebrovascular disease given vasoconstrictive mechanism.
- Cluster headache: High-flow oxygen and subcutaneous sumatriptan first-line for acute attacks, given rapid onset and severity; verapamil is first-line prophylaxis during a cluster bout, requiring ECG monitoring given dose-dependent cardiac conduction effects; monitor attack frequency and response, and consider short-course corticosteroids as a bridge while prophylaxis takes effect; occipital nerve block is an option for refractory cases.
- Trigeminal neuralgia: Carbamazepine first-line, often with dramatic response supporting the diagnosis; escalate to microvascular decompression or stereotactic radiosurgery for drug-refractory disease or intolerable side effects; monitor sodium (carbamazepine-induced hyponatraemia) and drug levels; investigate for an underlying cause (vascular compression, multiple sclerosis) with MRI, particularly in younger patients or bilateral symptoms.
- Bell's palsy: Oral corticosteroids started within 72 hours of onset first-line to improve recovery; antivirals may be added for severe presentations though evidence for benefit alone is weaker; eye protection (lubricants, taping at night) is essential given risk of exposure keratopathy from incomplete eye closure; monitor for recovery over weeks to months, and reconsider diagnosis (stroke, tumour, Lyme disease) if atypical features or non-recovery.
- Guillain-Barré syndrome: IVIG or plasma exchange first-line, started as soon as possible after diagnosis, with equal efficacy between the two; monitor respiratory function (forced vital capacity) closely given risk of rapid progression to respiratory failure requiring ventilation, and autonomic function (arrhythmia, blood pressure lability); avoid corticosteroids, which lack proven benefit in GBS unlike CIDP; early ICU involvement is warranted for rapidly progressive or bulbar-involved disease.
- Myasthenia gravis (crisis): Plasma exchange or IVIG first-line for myasthenic crisis with respiratory/bulbar compromise; monitor respiratory function (forced vital capacity, negative inspiratory force) closely given risk of rapid deterioration requiring ventilation; avoid or use cautiously drugs that worsen neuromuscular transmission (aminoglycosides, certain beta-blockers, magnesium); identify and treat any precipitant (infection, medication change).
- Myasthenia gravis (stable): Pyridostigmine first-line for symptomatic control; add corticosteroids or a steroid-sparing immunosuppressant/biologic for inadequate control; consider thymectomy in generalised disease, particularly with thymoma or in younger patients with acetylcholine receptor antibody-positive disease; monitor symptom control and for medication side effects; educate on crisis-precipitating drugs and situations (infection, surgery).
- Multiple sclerosis (relapse): High-dose IV (or oral) corticosteroids first-line to shorten relapse duration, though this does not alter long-term disability; ensure the patient is established on an appropriate disease-modifying therapy for long-term relapse/progression prevention, escalating therapy for breakthrough disease activity; monitor with MRI for new lesion activity and clinical relapse rate; plasma exchange is considered for severe steroid-refractory relapses.
- Parkinson's disease: Levodopa (with a peripheral decarboxylase inhibitor) first-line for most patients, particularly older patients, with dopamine agonists or MAO-B inhibitors as alternatives in younger patients to delay levodopa-related motor complications; escalate to deep brain stimulation for motor fluctuations refractory to optimised medical therapy; monitor for motor complications (wearing-off, dyskinesia) and non-motor symptoms (cognitive decline, autonomic dysfunction, depression) which significantly affect quality of life.
- Alzheimer's disease: Cholinesterase inhibitors first-line for mild-moderate disease, with memantine added or used alone in moderate-severe disease; monitor cognitive trajectory (standardised testing) and function; manage behavioural and psychological symptoms non-pharmacologically first-line given antipsychotic risks in dementia; newer anti-amyloid monoclonal antibodies are an option in select early, biomarker-confirmed disease under specialist supervision given infusion reaction and ARIA (amyloid-related imaging abnormality) monitoring requirements.
- Normal pressure hydrocephalus: Large-volume lumbar puncture (or extended lumbar drain trial) first-line to predict response before committing to surgery; ventriculoperitoneal shunting is definitive for those with a positive trial response, particularly gait improvement; monitor gait, cognition, and urinary symptoms (the classic triad) pre- and post-intervention; shunt complications (infection, over-drainage, subdural haematoma) require ongoing surveillance.
- Idiopathic intracranial hypertension: Weight loss and acetazolamide first-line for medical management; escalate to optic nerve sheath fenestration or CSF diversion (shunt) for progressive visual loss despite medical therapy; monitor visual fields and acuity closely, as visual loss can be irreversible if untreated; therapeutic lumbar puncture provides temporary relief while definitive management is arranged.
- Cerebral abscess: Empirical broad-spectrum antibiotics plus neurosurgical aspiration/drainage first-line for most abscesses, particularly those >2.5cm or causing mass effect; smaller abscesses may respond to antibiotics alone with close monitoring; monitor with serial imaging to confirm resolution and neurological status for deterioration; identify and treat the source (sinusitis, otitis, endocarditis, haematogenous spread) concurrently.
- Bacterial meningitis: Empirical IV antibiotics (covering the likely pathogens by age/risk factors) started immediately, without waiting for lumbar puncture if this would delay treatment, plus dexamethasone (particularly for pneumococcal meningitis) to reduce neurological sequelae; monitor neurological status, and repeat imaging/LP if not improving as expected; contact prophylaxis for close contacts in meningococcal disease; this is a medical emergency where delay materially worsens outcome.
- Viral encephalitis (HSV): Empirical IV aciclovir started immediately on clinical suspicion, without waiting for PCR confirmation, given high mortality/morbidity if treatment is delayed; monitor neurological status, repeat CSF HSV PCR if initially negative but suspicion remains high, and repeat imaging for complications; continue treatment for the full course (typically 14-21 days) even if early PCR is negative, if clinical suspicion remains high.
- Spinal cord compression (malignant): Urgent high-dose corticosteroids plus emergency MRI whole spine first-line on clinical suspicion, given time-critical risk of irreversible paralysis; escalate to urgent radiotherapy or surgical decompression depending on tumour radiosensitivity, spinal stability, and prior radiotherapy; monitor neurological status (motor/sensory level, bladder/bowel function) closely, as this is a neuro-oncological emergency requiring same-day assessment.
- Cervical spondylotic myelopathy: Surgical decompression is first-line for moderate-severe or progressive myelopathy, as conservative management alone is unlikely to reverse cord dysfunction; conservative management (physiotherapy, collar) may be considered for mild, non-progressive disease with close monitoring; monitor neurological function (gait, hand dexterity, bladder function) for progression, which should prompt surgical referral; earlier surgery before severe deficits develop is associated with better recovery.
- Essential tremor: Propranolol or primidone first-line for symptomatic action tremor affecting function; escalate to deep brain stimulation or focused ultrasound thalamotomy for severe, medication-refractory, functionally disabling tremor; monitor tremor severity and functional impact; distinguish from Parkinsonian rest tremor, as management and prognosis differ substantially.
- Restless legs syndrome: Iron studies and correction of iron deficiency first-line, as this is a common and reversible contributor; dopamine agonists or alpha-2-delta ligands (gabapentin, pregabalin) for persistent symptomatic disease; monitor for augmentation (worsening/earlier symptom onset) with long-term dopamine agonist use, which may require switching drug class; review medications (antihistamines, antidepressants) that can exacerbate symptoms.
- Amyotrophic lateral sclerosis: Riluzole first-line, providing modest survival benefit; supportive multidisciplinary management (respiratory support with NIV, nutritional support including gastrostomy, communication aids) is central to care given the incurable, progressive nature of the disease; monitor respiratory function (forced vital capacity) regularly to time NIV initiation; early palliative care involvement and advance care planning discussions are appropriate given prognosis.
- Transverse myelitis: High-dose IV corticosteroids first-line, with plasma exchange added for severe or steroid-refractory presentations; investigate for an underlying cause (multiple sclerosis, neuromyelitis optica, infection, autoimmune disease) as this guides longer-term disease-modifying therapy; monitor neurological function (motor, sensory, bladder/bowel) and MRI for lesion evolution; distinguishing idiopathic from NMOSD/MS-associated disease is important given differing long-term treatment and relapse risk.
- Acute disseminated encephalomyelitis: High-dose IV corticosteroids first-line, typically following a recent infection or vaccination; escalate to IVIG or plasma exchange for steroid-refractory disease; monitor neurological status and MRI, as ADEM is typically monophasic with a generally favourable prognosis in children; distinguish from multiple sclerosis (which requires different long-term management) based on monophasic course and multifocal presentation.
- Neuromyelitis optica spectrum disorder: High-dose IV corticosteroids plus plasma exchange first-line for acute attacks, given typically severe attacks with poor spontaneous recovery; long-term immunosuppression (rituximab or complement/IL-6 pathway inhibitors) is essential for relapse prevention, as this differs fundamentally from MS management; monitor aquaporin-4 antibody status and attack frequency; avoid certain MS disease-modifying therapies (interferon-beta, natalizumab), which can worsen NMOSD.
- Chronic inflammatory demyelinating polyneuropathy: IVIG, plasma exchange, or corticosteroids first-line, each with roughly comparable efficacy allowing individualised choice; escalate to combination therapy or other immunosuppressants for refractory/relapsing disease; monitor strength, function, and nerve conduction studies to assess and guide ongoing treatment need; unlike GBS, corticosteroids are effective and often used given the chronic relapsing/progressive course.
- Diabetic autonomic neuropathy: Optimise glycaemic control first-line to slow progression, with symptomatic treatment targeted to the affected system (fludrocortisone/midodrine for orthostatic hypotension, prokinetics for gastroparesis); monitor blood pressure (lying/standing), cardiac autonomic testing, and gastrointestinal/genitourinary symptoms; screen for silent myocardial ischaemia given blunted anginal warning symptoms from autonomic denervation.
- Charcot-Marie-Tooth disease: Supportive management (physiotherapy, orthotics/ankle-foot orthoses, occupational therapy) is the mainstay, as no disease-modifying pharmacotherapy currently exists; monitor for progressive weakness, foot deformity, and functional decline; genetic testing confirms subtype and informs family counselling given variable inheritance patterns; avoid neurotoxic drugs (vincristine and certain others) which can precipitate acute deterioration in susceptible subtypes.
- Wernicke's encephalopathy: Immediate high-dose IV thiamine first-line, given before or alongside any glucose administration, as glucose without thiamine can precipitate or worsen the condition in at-risk patients; treat empirically on clinical suspicion without waiting for confirmatory testing, given risk of irreversible progression to Korsakoff syndrome if delayed; monitor the classical triad (confusion, ataxia, ophthalmoplegia), though all three are often not present together; screen at-risk patients (alcohol use disorder, malnutrition, bariatric surgery) proactively.
- Korsakoff syndrome: High-dose thiamine continued alongside abstinence support first-line, though established amnestic syndrome often shows limited reversibility once fully developed, unlike the acute Wernicke phase; supportive cognitive rehabilitation and structured care given persistent anterograde/retrograde amnesia and confabulation; monitor cognitive function and nutritional status long-term; prevention through prompt thiamine treatment of Wernicke's encephalopathy is the most effective strategy.
- Cerebral venous sinus thrombosis: Anticoagulation (typically low-molecular-weight heparin, even in the presence of associated haemorrhagic infarction) first-line, as this is the definitive treatment reducing propagation and improving outcome; escalate to endovascular thrombectomy for severe/deteriorating cases despite anticoagulation; monitor neurological status and for raised intracranial pressure (papilloedema); identify and address prothrombotic risk factors (oral contraceptives, pregnancy, thrombophilia).
- Chronic subdural haematoma: Surgical burr-hole drainage first-line for symptomatic haematomas causing significant mass effect or neurological deficit; conservative management with serial imaging is reasonable for small, asymptomatic haematomas, particularly in patients on anticoagulation where reversal risk must be weighed; monitor neurological status and repeat imaging for re-accumulation, which is not uncommon after drainage; identify and manage anticoagulation/antiplatelet use, a common contributing factor especially in the elderly.
- Acute subdural haematoma: Urgent surgical evacuation (craniotomy) first-line for significant haematomas with mass effect or neurological deterioration; conservative management with close monitoring for small, minimally symptomatic haematomas; monitor neurological status (GCS) closely and repeat imaging for expansion; reverse any anticoagulation immediately given time-critical risk of herniation.
- Extradural haematoma: Urgent surgical evacuation is first-line and often life-saving, particularly with a lucid interval followed by rapid deterioration, a classic presentation; small, asymptomatic extradural haematomas without mass effect may be observed closely with serial imaging; monitor neurological status (GCS) very closely, as deterioration can be rapid; this is a neurosurgical emergency given the classically arterial (middle meningeal artery) bleeding source.
- Traumatic brain injury (moderate-severe): Airway protection, ICP monitoring, and control of secondary brain injury (avoiding hypoxia/hypotension) first-line per established protocols; escalate to decompressive craniectomy for refractory raised intracranial pressure; monitor ICP, cerebral perfusion pressure, and neurological status continuously in a critical care setting; avoid routine prophylactic hyperventilation/hypothermia, which lack proven outcome benefit and carry risk.
- Diffuse axonal injury: Supportive critical care management (ICP control, avoidance of secondary insults) is the mainstay, as there is no specific reversal treatment for the primary axonal injury; monitor neurological status closely, recognising that clinical severity may be disproportionate to initial imaging findings; MRI (particularly susceptibility-weighted sequences) is more sensitive than CT for detecting the extent of injury; prognosis is variable and long-term rehabilitation needs should be anticipated early.
- Vestibular schwannoma (acoustic neuroma): Observation with serial MRI first-line for small, asymptomatic or minimally symptomatic tumours, particularly in older patients, given typically slow growth; stereotactic radiosurgery or microsurgical resection for growing/symptomatic tumours, chosen based on tumour size and patient factors; monitor hearing, facial nerve function, and tumour size on serial imaging; balance treatment choice against hearing preservation and facial nerve preservation goals.
- Meningioma (symptomatic): Surgical resection is first-line for symptomatic or growing meningiomas amenable to safe resection; stereotactic radiosurgery for smaller tumours, surgically inaccessible locations, or incomplete resection; observation with serial imaging is appropriate for small, asymptomatic, incidentally found meningiomas given typically slow growth; monitor for recurrence with periodic imaging, particularly for higher-grade or incompletely resected tumours.
- Glioblastoma: Maximal safe surgical resection followed by concurrent chemoradiotherapy (temozolomide-based) and adjuvant chemotherapy is first-line (the Stupp protocol); tumour-treating fields may be added as adjunctive therapy; monitor with serial MRI for progression, recognising pseudoprogression can mimic true progression early after chemoradiotherapy; prognosis remains poor overall, and early palliative care/advance care planning discussion is appropriate given typical disease trajectory.
- Low-grade glioma: Maximal safe surgical resection first-line, with the extent of resection significantly influencing prognosis; adjuvant radiotherapy and chemotherapy for higher-risk features (residual tumour, older age, certain molecular markers); monitor with serial MRI for transformation to higher-grade disease, which can occur over years; molecular profiling (IDH mutation, 1p/19q co-deletion) guides both prognosis and treatment intensity.
- Pituitary apoplexy: Urgent stress-dose IV corticosteroids first-line given risk of coexisting acute adrenal insufficiency, even before confirming the diagnosis if clinical suspicion is high; escalate to urgent surgical decompression for significant visual loss, altered consciousness, or severe ophthalmoplegia; monitor visual fields, consciousness level, and pituitary hormone axes; conservative management with close monitoring is reasonable for mild presentations without significant visual/neurological compromise.
- Chiari malformation (symptomatic): Surgical posterior fossa decompression is first-line for symptomatic Chiari malformation (headache, syrinx, brainstem/cerebellar signs); asymptomatic, incidentally found malformations are typically observed without intervention; monitor symptoms and for syrinx development/progression on MRI; assess for associated syringomyelia, which often improves with successful decompression.
- Syringomyelia (symptomatic): Treat the underlying cause first-line where identifiable (Chiari decompression, tumour resection, tethered cord release), as syrinx often improves once the causative obstruction to CSF flow is addressed; direct syrinx shunting is reserved for cases without an identifiable/treatable underlying cause or persistent symptoms after treating the cause; monitor neurological function and syrinx size on serial MRI.
- Cervical radiculopathy: Conservative management (physiotherapy, analgesia, short course of oral corticosteroids for severe pain) first-line, as most cases improve without surgery; escalate to surgical decompression for progressive motor deficit, severe unremitting pain, or failure of conservative management; monitor neurological function (specific myotome/dermatome) for progression; imaging correlation with clinical findings is important given high rates of asymptomatic disc abnormalities on MRI.
- Peripheral facial nerve palsy (traumatic): Early surgical decompression is considered for complete paralysis with evidence of nerve transection or rapidly progressive/complete palsy following significant trauma (particularly temporal bone fracture), as outcomes are better with earlier intervention; conservative management with eye protection for incomplete or gradually evolving palsy; monitor facial nerve function serially (electroneurography can help predict recovery/guide surgical timing); protect the cornea given risk of exposure keratopathy.
- Tension headache (chronic): Amitriptyline first-line prophylaxis for chronic tension-type headache; limit acute analgesic use to avoid medication overuse headache, which commonly complicates chronic headache disorders; monitor headache frequency and analgesic consumption via a headache diary; address contributing lifestyle/psychological factors (stress, sleep, posture) as part of a comprehensive management plan.
- Medication overuse headache: Withdrawal of the overused acute medication is the essential first-line treatment, as continued use perpetuates the cycle; bridging therapy (short corticosteroid course, or a preventive agent) can ease the withdrawal period; monitor headache frequency during and after withdrawal, which often worsens transiently before improving; address the underlying primary headache disorder with appropriate prophylaxis once overuse is resolved.
- Cervicogenic headache: Physiotherapy targeting cervical spine mobility and posture first-line; add cervical facet or occipital nerve blocks for diagnostic confirmation and symptomatic relief in refractory cases; monitor headache frequency and cervical range of motion; distinguish carefully from migraine/tension-type headache, as management differs and misdiagnosis is common given overlapping features.
- Autonomic dysreflexia (spinal cord injury): Immediate removal of the noxious stimulus (bladder distension, faecal impaction, tight clothing) is the essential first-line action, as this is the usual trigger and its removal often resolves the episode; sit the patient upright and treat severe hypertension with a short-acting antihypertensive if the stimulus cannot be immediately identified/removed; monitor blood pressure closely given risk of hypertensive emergency (stroke, seizure); this is a medical emergency in patients with spinal cord injury at or above T6.
- Spinal muscular atrophy: Disease-modifying therapy (nusinersen, onasemnogene abeparvovec gene therapy, or risdiplam) started as early as possible, ideally pre-symptomatically via newborn screening, first-line, as these have transformed the natural history of the disease; supportive multidisciplinary care (respiratory support, nutrition, orthopaedic management of scoliosis) remains essential alongside; monitor motor function with standardised scales and respiratory function; genetic counselling for families given autosomal recessive inheritance.
- Duchenne muscular dystrophy: Corticosteroids first-line, started once motor decline begins, to slow disease progression and prolong ambulation; exon-skipping or gene-targeted therapies are available for eligible genetic subtypes; monitor cardiac (echocardiography, as dilated cardiomyopathy is near-universal) and respiratory function (which drive mortality) regularly, with proactive respiratory support and cardioprotective medication; multidisciplinary care (physiotherapy, orthopaedic management of scoliosis/contractures) is essential.
- Periodic limb movement disorder: Treatment is generally reserved for cases causing significant sleep disruption or daytime symptoms, using similar agents to restless legs syndrome (dopamine agonists, alpha-2-delta ligands) first-line; check and correct iron deficiency as a contributing/reversible factor; monitor with polysomnography to confirm diagnosis and assess treatment response; distinguish from restless legs syndrome, with which it frequently coexists but is a distinct diagnosis based on the movement pattern during sleep.
- Narcolepsy: Scheduled daytime naps and stimulant medication (modafinil first-line) for excessive daytime sleepiness; add sodium oxybate or a specific anti-cataplexy agent for narcolepsy with cataplexy; monitor symptom control (sleepiness, cataplexy frequency) and, given cardiovascular stimulant effects, cardiovascular status on stimulant therapy; polysomnography plus multiple sleep latency testing confirms diagnosis and helps exclude other causes of hypersomnolence.
Infectious Disease
- Multibacillary leprosy: Multidrug therapy (rifampicin, dapsone, clofazimine) for 12 months is first-line per WHO protocol; escalate corticosteroids for reversal (type 1) reactions or erythema nodosum leprosum (type 2, sometimes needing thalidomide where available); monitor for nerve function impairment at each visit, as early detection and steroid treatment of neuritis prevents permanent disability; screen household contacts and provide single-dose rifampicin prophylaxis where indicated.
- Secondary syphilis: Single dose IM benzathine penicillin G is first-line; use an alternative regimen (doxycycline) only if genuinely penicillin-allergic, as penicillin desensitisation is preferred in pregnancy given no proven alternative; monitor non-treponemal titres (RPR/VDRL) at 6 and 12 months to confirm serological response; screen for and treat sexual partners, and test for HIV and other STIs concurrently given shared risk factors.
- Genital herpes: Oral aciclovir/valaciclovir first-line for the initial episode, shortening duration and severity; suppressive daily therapy for frequent recurrences (>6/year) or to reduce transmission risk to partners; monitor recurrence frequency; in pregnancy, suppressive therapy from 36 weeks reduces risk of neonatal transmission, and active lesions at delivery warrant caesarean section.
- Chlamydial urethritis/cervicitis: Doxycycline first-line (azithromycin as an alternative, particularly in pregnancy where doxycycline is avoided); treat presumptively for gonorrhoea co-infection if local prevalence is high or testing unavailable; monitor for and treat sexual partners; test of cure is not routinely needed except in pregnancy, where re-testing is recommended given consequences of treatment failure.
- Gonorrhoea: Single-dose IM ceftriaxone first-line, with dual therapy historically added but increasingly ceftriaxone monotherapy per updated resistance-pattern guidance; treat presumptively for chlamydia co-infection; monitor for treatment failure given rising antimicrobial resistance, with test of cure recommended in pharyngeal infection or if symptoms persist; screen and treat sexual partners and test for other STIs including HIV.
- Genital tract tuberculosis: Standard multidrug anti-tuberculous therapy (as for pulmonary TB) is first-line, typically for 6 months; surgery is reserved for complications (tubo-ovarian abscess, persistent pelvic mass) not responding to medical therapy; monitor treatment response clinically and with imaging; counsel on infertility risk, as genital TB is a significant cause of tubal factor infertility even after successful treatment.
- Enteric (typhoid) fever: Empirical antibiotics (ceftriaxone or a fluoroquinolone depending on local resistance patterns) first-line, narrowed once sensitivities available; escalate to high-dose dexamethasone alongside antibiotics for severe disease with delirium/shock; monitor for complications (intestinal perforation, GI bleeding) particularly in the third week of untreated illness; identify chronic carriers (positive stool culture beyond 12 months) who pose ongoing public health risk.
- Malaria (uncomplicated P. falciparum): Artemisinin-based combination therapy (ACT) first-line per local resistance patterns; monitor parasitaemia clearance and clinical response over 48-72 hours, escalating to treatment for severe malaria if deterioration occurs; in pregnancy, ACTs are preferred in the second/third trimester with quinine-based regimens historically used in the first, though current guidance increasingly supports ACTs throughout; ensure primaquine (with G6PD testing first) for radical cure if P. vivax/ovale co-infection is possible.
- Severe/complicated malaria: IV artesunate is first-line, superior to quinine for reducing mortality in severe malaria; monitor for complications (cerebral malaria, acute kidney injury, severe anaemia, hypoglycaemia) with close haemodynamic and neurological monitoring, often requiring ICU care; check for post-artesunate delayed haemolysis over the following weeks; treat hypoglycaemia aggressively as it is both a complication and a marker of severity.
- Dengue fever (without warning signs): Supportive care (paracetamol for fever/pain, adequate oral hydration) is first-line, as there is no specific antiviral therapy; avoid NSAIDs and aspirin given bleeding risk; monitor for warning signs (abdominal pain, persistent vomiting, mucosal bleeding, lethargy) that signal progression to severe dengue, particularly around defervescence (days 3-7); daily full blood count to track haematocrit and platelet trend guides need for escalation.
- Dengue haemorrhagic fever/shock: Careful, protocolised IV fluid resuscitation first-line, titrated closely to avoid both under-resuscitation (shock) and over-resuscitation (fluid overload, a major cause of mortality); monitor haematocrit, platelet count, and vital signs frequently (often hourly during critical phase); platelet transfusion is reserved for significant active bleeding rather than low count alone; the critical phase (plasma leakage) typically occurs around defervescence and requires the closest monitoring.
- Leptospirosis: IV penicillin or ceftriaxone first-line for moderate-severe disease, with doxycycline for milder disease/prophylaxis; monitor renal function (Weil's disease causing renal failure), liver function, and for pulmonary haemorrhage, a major cause of mortality; supportive dialysis for renal failure; occupational/environmental exposure history (water contact, rodent exposure) supports diagnosis in endemic settings.
- Rabies (post-exposure): Immediate wound washing with soap and water first-line, followed promptly by rabies vaccine series and rabies immunoglobulin (infiltrated around the wound) for category III exposures; there is no effective treatment once symptoms develop, making prompt post-exposure prophylaxis essential; monitor wound healing and completion of the full vaccine schedule; category of exposure (contact, broken skin, mucous membrane/deep bite) determines whether immunoglobulin is needed.
- Tetanus: Wound debridement plus human tetanus immunoglobulin and metronidazole first-line, alongside completing/boosting active tetanus vaccination; escalate to muscle relaxants/sedation and ventilatory support in an ICU for severe spasms/autonomic instability; monitor for autonomic dysfunction (labile blood pressure, arrhythmia) and respiratory compromise from laryngospasm; a dark, quiet environment reduces spasm-triggering stimuli.
- Cholera: Aggressive oral or IV rehydration (per severity) first-line, as fluid loss is the primary driver of mortality; add a single-dose antibiotic (doxycycline or azithromycin) to shorten duration and reduce transmission in moderate-severe cases; monitor hydration status and stool output closely to guide ongoing fluid replacement; zinc supplementation reduces duration/severity in children.
- Amoebic dysentery: Metronidazole (or tinidazole) first-line for invasive disease, followed by a luminal agent (paromomycin) to eradicate intestinal cyst carriage and prevent relapse/transmission; monitor clinical response and consider imaging for liver abscess if fever/right upper quadrant pain persist; distinguish from bacterial dysentery via stool microscopy/antigen testing, as management differs.
- Giardiasis: Metronidazole or tinidazole first-line; monitor symptom resolution, as post-infectious lactose intolerance can cause persistent symptoms after successful treatment; investigate for and treat all household/close contacts with symptoms given faecal-oral transmission; consider an alternative agent for treatment failure, as resistance is increasingly recognised.
- HIV infection (newly diagnosed): Immediate initiation of combination antiretroviral therapy first-line regardless of CD4 count, as 'treat all' improves outcomes and reduces transmission; monitor CD4 count and viral load at baseline and periodically to confirm viral suppression; screen for opportunistic infection risk (TB, cryptococcal antigen if CD4 low) and coinfections (hepatitis B/C, syphilis) before/at initiation; counsel on adherence, as resistance develops rapidly with suboptimal adherence.
- Pneumocystis jirovecii pneumonia: High-dose co-trimoxazole, with corticosteroids for moderate-severe hypoxaemia.
- Cryptococcal meningitis: Induction with IV amphotericin B plus flucytosine first-line, followed by consolidation and maintenance fluconazole; carefully manage raised intracranial pressure with therapeutic lumbar puncture, as this significantly affects survival; monitor opening pressure at each LP and clinical response; delay antiretroviral therapy initiation by several weeks in HIV-associated disease to reduce risk of immune reconstitution inflammatory syndrome.
- Toxoplasmosis (cerebral, HIV-related): Pyrimethamine plus sulfadiazine (with folinic acid) first-line; monitor clinical and radiological response at 2 weeks, with brain biopsy considered for non-response given differential diagnosis of primary CNS lymphoma; start antiretroviral therapy after a short delay to reduce IRIS risk; secondary prophylaxis is continued until sustained CD4 recovery on ART.
- Latent tuberculosis infection: Isoniazid for 6-9 months, or shorter rifamycin-based regimens (3-4 months), first-line depending on drug interactions and adherence considerations; monitor liver function periodically, particularly with isoniazid or in those with pre-existing liver disease; exclude active TB before starting treatment (chest X-ray, symptom screen) to avoid inadequate monotherapy of active disease; prioritise treatment in high-risk contacts (HIV, young children, immunosuppressed).
- Multidrug-resistant tuberculosis: All-oral bedaquiline-based regimens (with linezolid and other second-line agents guided by resistance testing) are now first-line, replacing longer injectable-containing regimens; treatment duration is typically 6-9 months for standardised shorter regimens where eligible; monitor for drug toxicity (QT prolongation with bedaquiline, peripheral neuropathy/myelosuppression with linezolid) and sputum culture conversion; directly observed therapy improves adherence given the complexity and duration of treatment.
- Hepatitis B (chronic, active): Tenofovir or entecavir first-line for active chronic hepatitis B with elevated viral load/ALT or evidence of liver disease; monitor HBV DNA, ALT, and for cirrhosis/hepatocellular carcinoma development with regular surveillance (ultrasound +/- AFP); screen and vaccinate close contacts; in pregnancy, tenofovir is used in the third trimester for high viral load to reduce mother-to-child transmission alongside infant immunoprophylaxis.
- Hepatitis C (chronic): Direct-acting antiviral combination therapy (typically 8-12 weeks) is first-line, achieving cure (sustained virological response) in the great majority of patients regardless of genotype with modern pan-genotypic regimens; monitor HCV RNA at end of treatment and 12 weeks after to confirm cure; screen for and manage cirrhosis (ongoing HCC surveillance is required even after cure if cirrhosis is present); assess for drug interactions before starting DAAs.
- Herpes zoster: Antiviral therapy (aciclovir/valaciclovir) started early, plus analgesia for pain.
- Chickenpox (varicella, uncomplicated): Supportive care (antihistamines for itch, paracetamol for fever, avoiding aspirin given Reye syndrome risk) is first-line in healthy children, as the disease is usually self-limiting; oral aciclovir for adults, adolescents, or those with risk factors for severe disease given higher complication rates in these groups; monitor for secondary bacterial skin infection and, rarely, pneumonia/encephalitis; varicella-zoster immunoglobulin for susceptible high-risk contacts (immunocompromised, pregnant, neonates) after significant exposure.
- Measles: Supportive care and vitamin A supplementation; no specific antiviral therapy.
- Mumps: Supportive care (analgesia, hydration) is first-line, as no specific antiviral therapy exists; monitor for complications (orchitis, pancreatitis, meningitis, rare permanent deafness); testicular support and analgesia for orchitis, which can cause testicular atrophy though rarely infertility; isolate during the infectious period and ensure MMR vaccination status is addressed in contacts.
- Infectious mononucleosis: Supportive care (rest, analgesia, hydration) is first-line, as antivirals lack proven benefit; avoid amoxicillin/ampicillin, which characteristically causes a widespread rash in EBV infection and can cause diagnostic confusion; monitor for splenomegaly and advise against contact sports for 3-4 weeks given splenic rupture risk; consider corticosteroids only for severe complications (airway obstruction from tonsillar swelling, severe haemolytic anaemia).
- Scrub typhus: Doxycycline first-line, with rapid clinical response typically supporting the diagnosis; azithromycin is an alternative in pregnancy or children where doxycycline is relatively contraindicated (though short courses in children are now often considered acceptable); monitor for multi-organ involvement (ARDS, myocarditis, meningoencephalitis) in severe/delayed presentations; look for the characteristic eschar, which aids diagnosis in endemic areas.
- Brucellosis: Combination doxycycline plus rifampicin (or streptomycin) for at least 6 weeks first-line, as monotherapy carries high relapse rates; monitor clinical response and inflammatory markers, with longer courses/combination therapy for focal complications (spondylitis, endocarditis); investigate exposure history (unpasteurised dairy, livestock contact) which supports diagnosis and informs public health/occupational counselling.
- Candidaemia: Echinocandin first-line empirical therapy pending speciation/susceptibility, particularly in critically ill or recently azole-exposed patients; step down to fluconazole for susceptible species once stable; remove/exchange central venous catheters where feasible, as source control significantly affects outcome; monitor with repeat blood cultures to confirm clearance and screen for endophthalmitis with dilated fundoscopy given risk of ocular seeding.
- Invasive aspergillosis: Voriconazole first-line for invasive pulmonary/disseminated disease; isavuconazole is an alternative with a more favourable toxicity/interaction profile; monitor voriconazole levels (narrow therapeutic window, significant interactions) and galactomannan/imaging response; reduce immunosuppression where feasible, and consider surgical resection for localised refractory disease or before further chemotherapy in haematology patients.
- Sepsis with unknown source: Early broad-spectrum empirical antibiotics (within 1 hour) plus IV fluid resuscitation and source identification first-line, following sepsis bundle principles; escalate to vasopressor support for fluid-refractory hypotension; monitor lactate clearance, urine output, and haemodynamics closely; narrow antibiotics once a source/organism is identified, and actively search for an occult source (abscess, endocarditis) if initial work-up is unrevealing.
- Septic shock: IV fluid resuscitation and early broad-spectrum antibiotics first-line, with noradrenaline as first-line vasopressor for persistent hypotension despite fluids; add vasopressin or corticosteroids for refractory shock; monitor lactate clearance, mean arterial pressure, and end-organ perfusion continuously in a critical care setting; identify and achieve source control (drainage, debridement) as a priority alongside pharmacological therapy.
- Necrotising fasciitis: Urgent surgical debridement is first-line and time-critical, as antibiotics alone cannot control this rapidly progressive infection; broad-spectrum IV antibiotics (including clindamycin for antitoxin effect against toxin-producing organisms) started immediately alongside; monitor for the need for repeat debridement (often required within 24-48 hours) and for septic shock; this is a surgical emergency where delayed debridement is strongly associated with mortality.
- COVID-19 (severe/hypoxic): Supplemental oxygen and dexamethasone first-line for hypoxic disease; add remdesivir and/or an IL-6 inhibitor (tocilizumab) for progressive severe disease per current evidence-based protocols; monitor oxygenation trend and inflammatory markers, escalating respiratory support (high-flow, NIV, invasive ventilation) as needed; avoid corticosteroids in non-hypoxic disease given lack of benefit and potential harm.
- Influenza (high-risk patient): Oseltamivir started as early as possible (ideally within 48 hours of symptom onset) first-line in high-risk patients (elderly, pregnant, comorbid, immunocompromised); monitor for secondary bacterial pneumonia, a leading complication; treatment may still provide benefit beyond 48 hours in hospitalised/severe cases; annual vaccination remains the primary preventive strategy for future seasons.
- Toxic shock syndrome: Aggressive fluid resuscitation, source control (removal of tampon/packing, debridement of infected tissue), and antibiotics (covering toxin-producing Staphylococcus/Streptococcus, including clindamycin for antitoxin effect) first-line; escalate to IVIG for refractory shock, particularly streptococcal TSS; monitor haemodynamics and multi-organ function closely given rapid progression to multi-organ failure; this is a medical emergency requiring ICU-level monitoring.
- Staphylococcus aureus bacteraemia: IV antibiotics (flucloxacillin for MSSA, vancomycin or an alternative for MRSA) for a minimum duration (typically 2 weeks uncomplicated, 4-6 weeks for complicated/endocarditis) first-line; mandatory echocardiography to assess for endocarditis given significant risk regardless of clinical suspicion; monitor with repeat blood cultures to confirm clearance and identify/remove any removable source (line, abscess); infectious disease consultation improves outcomes in this condition.
- Osteomyelitis (chronic): Surgical debridement of necrotic/infected bone plus prolonged targeted IV then oral antibiotics (often 6+ weeks) first-line, as chronic osteomyelitis with sequestrum rarely resolves with antibiotics alone; monitor inflammatory markers and imaging response; consider local antibiotic delivery (beads, cement) and staged reconstruction for extensive bone loss; recurrence is common and long-term follow-up is needed.
- Diabetic foot infection (moderate-severe): Broad-spectrum IV antibiotics plus surgical debridement first-line for moderate-severe infection, with imaging (MRI) to assess for osteomyelitis; vascular assessment/revascularisation where significant peripheral arterial disease coexists, as perfusion critically affects healing; monitor wound response, glycaemic control, and offloading adherence; multidisciplinary diabetic foot team involvement improves limb salvage rates.
- Actinomycosis: Prolonged high-dose penicillin (often IV then oral, for weeks to months) first-line, given the characteristically indolent, fibrosing nature of infection requiring extended treatment; surgical debridement/drainage for abscess or extensive tissue involvement; monitor clinical and radiological response over the prolonged treatment course; consider the diagnosis in chronic, mass-like infections mimicking malignancy, particularly with characteristic sulfur granules on histology.
- Nocardiosis: Co-trimoxazole first-line (or combination therapy for severe/disseminated disease, particularly CNS involvement) for a prolonged course (months); monitor clinical and radiological response and screen for CNS involvement with brain imaging given tendency for dissemination, particularly in immunocompromised hosts; assess and address underlying immunosuppression as a contributing factor.
- Q fever: Doxycycline first-line for acute disease; prolonged combination therapy (doxycycline plus hydroxychloroquine) for months to years for chronic Q fever (endocarditis), given risk of relapse with shorter courses; monitor serology (phase I/II antibody titres) to distinguish acute from chronic disease and guide treatment duration; occupational/animal exposure history (livestock, especially parturition) supports diagnosis.
- Lyme disease (early localised): Oral doxycycline (or amoxicillin as an alternative, including in young children/pregnancy) for 10-14 days first-line for early localised disease (erythema migrans); monitor for progression to disseminated disease (neurological, cardiac, or joint involvement) if untreated or inadequately treated; single-dose post-exposure prophylaxis is considered after a high-risk tick bite in endemic areas under specific criteria.
- Lyme neuroborreliosis: IV ceftriaxone (or in some cases oral doxycycline for milder facial palsy alone) for 2-4 weeks first-line for CNS/neurological involvement; monitor neurological symptoms for resolution, which may be gradual even after adequate treatment; distinguish post-treatment symptoms (which do not indicate ongoing infection) from true treatment failure, as prolonged/repeated antibiotic courses are not supported by evidence and carry harm.
- Chikungunya fever: Supportive care (analgesia, hydration) is first-line, as there is no specific antiviral treatment; avoid NSAIDs/aspirin until dengue is excluded given overlapping presentation and bleeding risk in dengue; monitor for persistent/chronic arthralgia, which can last months to years and may need longer-term analgesic/anti-inflammatory management; vector control and mosquito avoidance are key preventive measures.
- Zika virus infection: Supportive care (analgesia, hydration) is first-line, as no specific antiviral treatment exists; avoid NSAIDs/aspirin until dengue is excluded; in pregnancy, monitor closely with serial ultrasound given risk of congenital Zika syndrome (microcephaly) and refer to specialist fetal medicine services; counsel on sexual transmission risk and appropriate precautions for a defined period after infection/exposure.
- Yellow fever: Supportive care (fluid/haemodynamic support, management of coagulopathy and renal/hepatic failure) is the mainstay, as no specific antiviral treatment exists; monitor liver function, coagulation, and renal function closely given risk of severe hepatorenal failure in the toxic phase; vaccination is the cornerstone of prevention and is highly effective, required for travel to/from endemic areas per international health regulations.
- Japanese encephalitis: Supportive care (ICU-level management of raised intracranial pressure, seizures, and respiratory support as needed) is the mainstay, as no specific antiviral treatment exists; monitor neurological status closely given risk of significant long-term neurological sequelae in survivors; vaccination is the primary prevention strategy in endemic/at-risk travellers; vector control reduces transmission at a population level.
- Filariasis (lymphatic): Diethylcarbamazine (or ivermectin/albendazole combinations in areas co-endemic for onchocerciasis, where DEC is avoided) first-line for active infection; supportive lymphoedema management (skin hygiene, compression, exercise) for established lymphatic damage, as this does not reverse with antifilarial treatment alone; monitor for allergic reactions to treatment from dying microfilariae; mass drug administration is a key public health control strategy in endemic regions.
- Onchocerciasis: Ivermectin first-line, given periodically (typically annually) as microfilaricidal treatment; monitor for ocular involvement (river blindness) with regular ophthalmological screening, as this drives the most serious long-term morbidity; avoid diethylcarbamazine in co-endemic areas given risk of severe ocular/systemic reactions; mass drug administration is the primary public health control strategy.
- Schistosomiasis: Praziquantel first-line, effective against the adult worm stage; monitor for chronic complications (hepatosplenic disease, bladder pathology/urothelial carcinoma risk with S. haematobium) with appropriate imaging surveillance in endemic exposure; repeat treatment may be needed as praziquantel has limited efficacy against immature stages; address water contact/exposure reduction as part of public health control.
- Ascariasis: Single-dose albendazole or mebendazole first-line; monitor for complications of heavy worm burden (intestinal obstruction, biliary/pancreatic duct obstruction) which may require surgical/endoscopic intervention in addition to antihelminthic therapy; mass deworming programmes in endemic areas reduce community burden, particularly in children where growth/nutritional impact is greatest.
- Hookworm infection: Single-dose albendazole or mebendazole first-line; treat associated iron deficiency anaemia with iron supplementation, as chronic blood loss from hookworm is a major cause of anaemia in endemic areas; monitor haemoglobin response; mass deworming and improved sanitation are key public health prevention strategies.
- Taeniasis (tapeworm): Single-dose praziquantel or niclosamide first-line for intestinal tapeworm infection; monitor for passage of segments confirming treatment success; counsel on prevention (thorough cooking of meat) and screen for neurocysticercosis risk in T. solium carriers, as autoinfection can lead to this more serious tissue-invasive form.
- Neurocysticercosis (viable cysts): Antihelminthic therapy (albendazole, sometimes with praziquantel) combined with corticosteroids first-line for viable parenchymal cysts, as treatment can provoke inflammation around dying cysts; anti-seizure medication for associated seizures, which are the most common presentation; monitor with serial imaging and neurological status; antihelminthic therapy is avoided in ocular or heavily calcified/degenerating cysts with significant surrounding oedema until inflammation is controlled, and hydrocephalus may require neurosurgical intervention.
- Hydatid disease (echinococcosis): Surgical resection (or PAIR - puncture, aspiration, injection, re-aspiration - for suitable cysts) is first-line for symptomatic or large cysts, combined with peri-procedural albendazole to reduce recurrence/seeding risk; albendazole alone for small, inoperable, or multiple cysts; monitor with serial imaging for recurrence; avoid unprotected percutaneous drainage without antihelminthic cover given anaphylaxis risk from cyst fluid leakage.
- Leishmaniasis (visceral): Liposomal amphotericin B first-line in most settings given superior efficacy/safety over pentavalent antimonials; monitor blood counts (pancytopenia is characteristic and should improve with treatment), renal function, and clinical response (resolution of fever, splenomegaly); screen for HIV coinfection, which significantly alters treatment response and relapse risk; relapse surveillance is important in immunocompromised patients.
- Leishmaniasis (cutaneous): Treatment approach depends on species/region and lesion characteristics; options include local therapy (intralesional antimonials, cryotherapy) for simple lesions or systemic therapy (antimonials, miltefosine) for complex/multiple lesions or those at risk of mucosal spread; monitor lesion healing and scarring; species identification helps predict risk of mucocutaneous spread, which changes management toward systemic therapy.
- African trypanosomiasis: Stage-specific therapy is essential: early haemolymphatic stage treated with pentamidine (T.b. gambiense) or suramin (T.b. rhodesiense); late CNS-stage disease requires CNS-penetrant therapy (fexinidazole or NECT combination therapy), as haemolymphatic-stage drugs do not adequately cross the blood-brain barrier; monitor CSF for staging (cell count, trypanosomes) to guide treatment choice; lumbar puncture is essential before treatment selection.
- Chagas disease (acute): Benznidazole (or nifurtimox) first-line, most effective when given in the acute phase; monitor for cardiac involvement (acute myocarditis) and treatment tolerability, as side effects are common and may limit the full course; screen for chronic Chagas cardiomyopathy/megacolon/megaoesophagus years later even after apparently successful acute treatment, as these complications can still develop; treatment in chronic phase has more debated benefit but is generally still offered, particularly in younger patients.
- Diphtheria: Diphtheria antitoxin first-line, given as early as possible (ideally on clinical suspicion, without waiting for culture confirmation) as it neutralises only unbound toxin; add antibiotics (penicillin or erythromycin) to eliminate the organism and prevent transmission; monitor airway (risk of obstruction from pseudomembrane) and cardiac status (myocarditis is a major cause of death); isolate and provide close contact prophylaxis given high transmissibility.
- Pertussis (infant, severe): Macrolide antibiotics first-line, most beneficial if started early though may not shorten established paroxysmal cough; supportive care with close monitoring for apnoea, cyanosis, and feeding difficulty, often requiring hospitalisation and sometimes ICU care in young infants; monitor oxygen saturation and for secondary bacterial pneumonia; prophylaxis for close contacts and maternal vaccination in pregnancy are key prevention strategies given highest severity/mortality in young unvaccinated infants.
- Botulism: Botulinum antitoxin first-line, given as early as possible to neutralise circulating unbound toxin, as it cannot reverse toxin already bound to nerve terminals; supportive respiratory care (often requiring prolonged ventilation) as recovery depends on nerve terminal regeneration over weeks to months; monitor respiratory function closely given risk of progressive descending paralysis leading to respiratory failure; identify the source (food-borne, wound, infant) as this affects specific management (wound debridement for wound botulism).
- Gas gangrene (clostridial myonecrosis): Urgent, extensive surgical debridement is first-line and time-critical, alongside high-dose IV penicillin plus clindamycin (for antitoxin effect); hyperbaric oxygen may be considered as an adjunct where available, though should not delay surgery; monitor for rapidly progressive systemic toxicity and shock; this is a surgical emergency where delayed debridement carries very high mortality.
- Anthrax (cutaneous): Oral ciprofloxacin or doxycycline first-line for uncomplicated cutaneous anthrax; escalate to IV combination antibiotic therapy for systemic involvement or evidence of toxaemia; monitor for progression to systemic disease, which is uncommon but serious; avoid incision/manipulation of the characteristic eschar, which can promote systemic spread; report to public health authorities given bioterrorism implications in unexplained clusters.
- Plague: IV or IM streptomycin (or gentamicin/doxycycline as alternatives) first-line, started as early as possible given high mortality if treatment is delayed, particularly in pneumonic plague; strict respiratory isolation for pneumonic plague given high person-to-person transmissibility; monitor for septicaemic spread and disseminated intravascular coagulation; report to public health authorities given outbreak and bioterrorism implications.
- Melioidosis: IV ceftazidime or a carbapenem for an intensive initial phase (2+ weeks) first-line, followed by a prolonged oral eradication phase (co-trimoxazole, typically 3-6 months) to prevent relapse, given intracellular organism persistence; monitor for abscess formation (multiple organs, including prostate/spleen) requiring drainage alongside antibiotics; screen for underlying diabetes, a major risk factor; relapse is common without completing the full eradication phase.
- Listeriosis: IV ampicillin (often with gentamicin for synergy in severe disease, particularly meningitis/bacteraemia) first-line, as Listeria is intrinsically resistant to cephalosporins, a common empirical meningitis choice that must be specifically supplemented; monitor for CNS involvement, which carries significant mortality; in pregnancy, treat promptly given risk of fetal loss/neonatal sepsis, and consider the diagnosis in unexplained febrile illness in pregnancy or immunocompromised/elderly patients.
- Toxoplasmosis (congenital): Combination pyrimethamine, sulfadiazine, and folinic acid for an extended course (typically 12 months) is first-line for confirmed congenital infection; monitor visual (chorioretinitis surveillance), auditory, and neurodevelopmental outcomes long-term given risk of delayed manifestations; maternal treatment during pregnancy (spiramycin, or pyrimethamine-sulfadiazine if fetal infection confirmed) reduces transmission/severity; screening programmes vary by region.
- Congenital rubella syndrome: Supportive, multidisciplinary management of the affected organ systems (cardiac, ophthalmological, audiological) is the mainstay, as there is no treatment for established congenital rubella syndrome; monitor hearing, vision, cardiac status, and developmental progress long-term; prevention through maternal rubella immunity/vaccination before pregnancy is the primary strategy, as this condition is now rare where vaccination coverage is high; infected infants shed virus for prolonged periods and require appropriate isolation precautions.
- Congenital cytomegalovirus infection: Oral valganciclovir (or IV ganciclovir) for symptomatic congenital CMV, particularly with CNS/hearing involvement, first-line, shown to improve hearing and neurodevelopmental outcomes; monitor blood counts (myelosuppression is a common side effect) and hearing/neurodevelopment long-term, as CMV-related hearing loss can be progressive; asymptomatic infection is generally not treated but still requires audiological follow-up given delayed-onset hearing loss risk.
- Herpes zoster ophthalmicus: Oral (or IV for severe/immunocompromised) antiviral therapy first-line, started promptly to reduce ocular complications; urgent ophthalmology referral given risk of keratitis, uveitis, and vision-threatening complications, particularly with nasociliary involvement (Hutchinson's sign); monitor visual acuity and for late complications (post-herpetic neuralgia, chronic ocular inflammation); topical corticosteroids for ocular inflammation are used under ophthalmology guidance alongside systemic antivirals.
- Fungal keratitis: Topical antifungal therapy (natamycin for filamentous fungi, or an azole/amphotericin for yeast) first-line, often requiring intensive frequent dosing; escalate to therapeutic keratoplasty for progressive disease despite medical therapy or impending perforation; monitor closely with serial slit-lamp examination given risk of rapid progression; avoid topical corticosteroids, which can worsen fungal keratitis; identify risk factors (trauma with vegetative matter, contact lens use) which support diagnosis.
- Mucormycosis (rhino-orbital-cerebral): Urgent surgical debridement combined with high-dose IV liposomal amphotericin B first-line, as this is a rapidly progressive, angioinvasive infection where delay is strongly associated with mortality; correct underlying predisposing factors (control hyperglycaemia/ketoacidosis, reduce immunosuppression where possible) alongside; monitor extent of disease with imaging and repeated surgical debridement as needed; this is a medical and surgical emergency requiring multidisciplinary (ENT, ophthalmology, infectious disease) input.
Rheumatology
- ANCA-associated vasculitis: Induction with high-dose corticosteroids plus rituximab or cyclophosphamide first-line for organ- or life-threatening disease, adding plasma exchange for severe pulmonary haemorrhage or rapidly progressive renal failure; maintenance with rituximab or azathioprine after remission; monitor ANCA titre trend, renal function, and for treatment-related infection/cytopenias; avotermin/avacopan can reduce steroid exposure in induction per current guidance.
- Takayasu arteritis: High-dose corticosteroids first-line, adding a steroid-sparing immunosuppressant (methotrexate, tocilizumab) for relapsing or refractory disease; escalate to vascular intervention (angioplasty/bypass) for critical stenosis once inflammation is controlled; monitor inflammatory markers (often unreliable alone) alongside vascular imaging (MR/CT angiography) for disease activity; blood pressure should be measured in all four limbs given differential vessel involvement.
- Antiphospholipid syndrome: Long-term anticoagulation (warfarin, target INR 2-3) first-line for thrombotic APS, as DOACs are less effective particularly in triple-positive disease; low-dose aspirin plus prophylactic-dose heparin for obstetric APS; monitor INR closely and for recurrent thrombosis despite therapeutic anticoagulation; catastrophic APS requires anticoagulation plus corticosteroids and plasma exchange/IVIG given high mortality.
- Rheumatoid arthritis: Methotrexate first-line conventional DMARD, escalating to biologic or targeted synthetic DMARD (TNF inhibitor, JAK inhibitor) for inadequate response at 3-6 months; monitor disease activity score, and full blood count/liver function on methotrexate; screen for latent TB and hepatitis B/C before biologics; use JAK inhibitors cautiously in older patients or those with cardiovascular/VTE risk factors given boxed warnings.
- Ankylosing spondylitis: NSAIDs first-line with regular physiotherapy/exercise programme; escalate to TNF inhibitor or IL-17 inhibitor biologic for inadequate response to NSAIDs (conventional DMARDs are ineffective for axial disease); monitor spinal mobility, inflammatory markers, and for extra-articular manifestations (uveitis, IBD); screen for and manage cardiovascular risk given increased association.
- Psoriatic arthritis: NSAIDs and conventional DMARD (methotrexate) first-line for peripheral disease, escalating to biologic therapy (TNF, IL-17, or IL-23 inhibitor) for inadequate response or axial/enthesitis-predominant disease; monitor joint counts, skin involvement, and nail changes; avoid IL-17 inhibitors in active inflammatory bowel disease given risk of exacerbation, preferring TNF or IL-23 inhibitors instead.
- Reactive arthritis: NSAIDs first-line for symptomatic joint control; add a short corticosteroid course or intra-articular injection for severe mono/oligoarthritis; treat any identified triggering infection (chlamydia, enteric pathogens) with appropriate antibiotics though this does not reliably alter arthritis course; monitor for chronicity, which occurs in a minority and may require DMARD therapy similar to other spondyloarthropathies.
- Polymyalgia rheumatica: Low-dose oral corticosteroids first-line with rapid dramatic symptomatic response supporting the diagnosis; taper slowly over 1-2 years to minimise relapse; monitor inflammatory markers and symptoms at each taper step, and screen for coexisting or evolving giant cell arteritis (visual symptoms, headache) which requires much higher-dose steroids; consider methotrexate as a steroid-sparing agent for relapsing or prolonged-course disease.
- Giant cell arteritis: Immediate high-dose corticosteroids first-line (started on clinical suspicion, without waiting for biopsy) to prevent irreversible visual loss; add tocilizumab for relapsing disease or as a steroid-sparing strategy; monitor inflammatory markers, visual symptoms, and temporal artery biopsy/ultrasound to confirm diagnosis; screen for aortitis/aneurysm given long-term risk, particularly in those with a prolonged disease course.
- Systemic sclerosis: Organ-specific therapy is the mainstay (ACE-I for renal crisis, PDE5 inhibitors/endothelin antagonists for pulmonary hypertension and Raynaud's, immunosuppression for progressive skin/lung fibrosis); monitor annual pulmonary function/echocardiography for early pulmonary hypertension and ILD detection; avoid high-dose corticosteroids, which can precipitate scleroderma renal crisis; nifedipine and avoidance of cold are first-line for Raynaud's phenomenon.
- Sjögren's syndrome: Symptomatic management (artificial tears/saliva, pilocarpine/cevimeline for secretomotor stimulation) first-line for sicca symptoms; add hydroxychloroquine or immunosuppression for systemic/extraglandular involvement; monitor for lymphoma risk (parotid swelling, cytopenias, low complement) given significantly increased incidence; screen for associated autoimmune conditions and congenital heart block risk in pregnancy if anti-Ro/La positive.
- Granulomatosis with polyangiitis: Induction with high-dose corticosteroids plus rituximab or cyclophosphamide first-line, as for other severe ANCA-associated vasculitis; add plasma exchange for severe renal failure or pulmonary haemorrhage; monitor ANCA titre, renal function, and for relapse, which is common and often requires re-induction; screen for chronic sinonasal and subglottic disease requiring separate ENT management.
- Polyarteritis nodosa: High-dose corticosteroids first-line, adding cyclophosphamide for severe or organ-threatening disease; treat associated hepatitis B (if present) with antivirals alongside immunosuppression, as HBV-associated PAN has a distinct management pathway prioritising antiviral therapy; monitor for mesenteric, renal, and neurological (mononeuritis multiplex) involvement; angiography may reveal characteristic microaneurysms guiding diagnosis.
- Behçet's disease: Colchicine first-line for mucocutaneous and mild joint disease; escalate to immunosuppression (azathioprine, TNF inhibitors) for major organ involvement (uveitis, vascular, neurological, GI); monitor for ocular involvement requiring urgent ophthalmology input given sight-threatening potential; anticoagulation for venous thrombosis is used cautiously given coexisting risk of pulmonary artery aneurysm and haemorrhage.
- Fibromyalgia: Patient education, graded exercise, and CBT first-line, as pharmacotherapy alone has modest effect; add low-dose amitriptyline, duloxetine, or pregabalin for inadequate response to non-pharmacological measures; monitor functional outcomes rather than relying solely on symptom scores; avoid opioids, which lack evidence of benefit and carry dependence risk in this population.
- Osteoarthritis (knee): Weight loss, exercise/physiotherapy, and topical/oral NSAIDs first-line; intra-articular corticosteroid injection for symptomatic flares refractory to first-line measures; escalate to total knee replacement for severe symptomatic disease impacting quality of life despite conservative therapy; monitor functional status and pain, and use NSAIDs cautiously in renal impairment, cardiovascular disease, or the elderly.
- Septic arthritis: Urgent joint aspiration for diagnosis followed by empirical IV antibiotics (covering Staphylococcus aureus) and surgical/arthroscopic washout, particularly for large joints or prosthetic joint infection; narrow antibiotics once organism identified, typically for 2-4 weeks; monitor clinical response, inflammatory markers, and repeat aspiration if not improving; treat as an orthopaedic emergency given risk of rapid cartilage destruction.
- Pseudogout (CPPD arthropathy): NSAIDs or intra-articular corticosteroid injection first-line for acute attacks, with colchicine as an alternative; low-dose colchicine or NSAID prophylaxis for recurrent attacks; monitor for underlying metabolic associations (hyperparathyroidism, haemochromatosis, hypomagnesaemia) particularly in younger or atypical presentations; joint aspiration with polarised microscopy confirms diagnosis and excludes septic arthritis, which must always be considered concurrently.
- Systemic sclerosis renal crisis: Urgent ACE-inhibitor therapy is first-line and disease-specific (uniquely, ACE-I are used even with rising creatinine, unlike most renal emergencies), titrated aggressively to control blood pressure; escalate to dialysis if renal failure progresses despite ACE-I therapy, with a meaningful chance of later renal recovery; monitor blood pressure and renal function closely, ideally with hospital admission; avoid high-dose corticosteroids, which are a recognised precipitant.
- Mixed connective tissue disease: Treatment is directed at the dominant clinical feature (arthritis, myositis, sclerodermatous, or lupus-like) using the corresponding disease-specific therapy; monitor for pulmonary arterial hypertension, which is a leading cause of mortality and warrants regular echocardiographic screening; monitor anti-U1-RNP titres and organ-specific serologies; overlap features may evolve over time, requiring reassessment of the predominant phenotype.
- Adult-onset Still's disease: High-dose corticosteroids first-line for systemic symptoms (fever, rash, arthritis); escalate to IL-1 or IL-6 inhibitor biologic therapy for steroid-refractory or relapsing disease; monitor ferritin (often markedly elevated and a useful activity marker), liver function, and for macrophage activation syndrome, a life-threatening complication requiring prompt recognition and treatment; exclude infection and malignancy before committing to immunosuppression given overlapping presentation.
- Relapsing polychondritis: Corticosteroids first-line for active inflammation, with dose guided by severity of organ involvement; escalate to immunosuppression (methotrexate, biologics) for relapsing or corticosteroid-refractory disease; monitor for airway involvement (tracheal/laryngeal chondritis), which can be life-threatening and may require stenting or tracheostomy; screen for associated haematological malignancy (myelodysplastic syndrome) particularly in older patients.
- IgG4-related disease: Corticosteroids first-line, with generally good initial response across affected organs; escalate to rituximab for relapsing or steroid-refractory disease, or as a steroid-sparing strategy; monitor serum IgG4 levels (imperfectly correlate with activity), organ imaging, and for fibrotic organ damage which may not reverse with treatment; biopsy with characteristic histopathology (storiform fibrosis, IgG4+ plasma cells) supports diagnosis and excludes malignancy mimics.
- Eosinophilic granulomatosis with polyangiitis: High-dose corticosteroids first-line, adding cyclophosphamide for severe organ-threatening (cardiac, GI, renal, neurological) disease, or mepolizumab (anti-IL-5) for milder/relapsing disease allowing steroid reduction; monitor eosinophil count, ANCA (positive in a subset), and cardiac assessment given risk of eosinophilic myocarditis; asthma control often needs to be managed alongside systemic therapy.
- Microscopic polyangiitis: Induction with high-dose corticosteroids plus rituximab or cyclophosphamide first-line, as for other ANCA-associated vasculitides; add plasma exchange for severe pulmonary haemorrhage or rapidly progressive glomerulonephritis; monitor renal function, ANCA titre, and pulmonary status; maintenance immunosuppression reduces relapse risk after induction remission is achieved.
- Cryoglobulinaemic vasculitis: Treat the underlying cause first-line (antiviral therapy for hepatitis C-associated disease, which is the most common cause); add corticosteroids plus rituximab or plasma exchange for severe organ-threatening disease (renal, neurological, cutaneous ulceration); monitor cryoglobulin levels, complement, and renal function; avoid prolonged immunosuppression alone without addressing underlying HCV, as this risks viral flare.
- Juvenile idiopathic arthritis: NSAIDs and intra-articular corticosteroids first-line for oligoarticular disease; escalate to methotrexate or biologic DMARD for polyarticular or systemic-onset disease, or inadequate response; monitor growth, joint damage, and screen regularly for asymptomatic uveitis (particularly ANA-positive oligoarticular disease) given risk of silent sight-threatening inflammation; multidisciplinary input (ophthalmology, physiotherapy) is essential given growth and development considerations.
- Familial Mediterranean fever: Colchicine first-line, both to control attack frequency and to prevent amyloidosis, the most serious long-term complication; escalate to IL-1 inhibitor biologics (anakinra, canakinumab) for colchicine-resistant disease; monitor for adherence (the major cause of treatment failure), inflammatory markers between attacks, and urine protein to detect evolving amyloid nephropathy; genetic counselling is relevant given autosomal recessive inheritance.
- Gout (acute flare): NSAIDs, colchicine, or corticosteroids first-line depending on comorbidity (NSAIDs avoided in renal impairment/heart failure, colchicine dose-reduced in renal impairment); do not start or stop urate-lowering therapy during an acute flare; monitor renal function and response; joint aspiration to exclude septic arthritis is warranted in atypical or first presentations, particularly with fever.
- Gout (chronic tophaceous): Urate-lowering therapy (allopurinol first-line, titrated to target serum urate <6mg/dL, or <5mg/dL with visible tophi) alongside flare prophylaxis (colchicine or low-dose NSAID) during initiation; escalate allopurinol dose gradually to reduce flare risk, using febuxostat as an alternative if intolerant; monitor serum urate to target and renal/liver function; screen for HLA-B*5801 before allopurinate in high-risk populations (e.g. Han Chinese, Thai) given severe hypersensitivity risk.
- Osteoarthritis (hip): Weight loss, exercise/physiotherapy, and analgesia (paracetamol/topical or oral NSAIDs) first-line; escalate to total hip replacement for severe symptomatic disease with functional impairment refractory to conservative measures; monitor pain and function, and use NSAIDs cautiously in renal impairment, cardiovascular disease, or older patients; intra-articular injection has a more limited role in the hip than the knee.
- Chronic low back pain (non-specific): Education, activity/exercise encouragement, and simple analgesia first-line, avoiding prolonged bed rest which worsens outcomes; escalate to structured physiotherapy programme, and consider CBT for pain-related disability; monitor for red flags (progressive neurological deficit, cauda equina symptoms, weight loss, fever) requiring urgent imaging, which are rare in non-specific back pain; avoid routine imaging in the absence of red flags, as it does not improve outcomes and increases inappropriate intervention.
- Spondylolisthesis (symptomatic): Physiotherapy and activity modification first-line for mild, stable, low-grade slips; escalate to surgical decompression/fusion for high-grade slips, progressive neurological deficit, or symptoms refractory to conservative management; monitor for progression on serial imaging, particularly in adolescents with growth remaining; sports restriction may be needed in symptomatic athletes with high-grade slips.
- Enteropathic arthritis: Treatment of the underlying inflammatory bowel disease (biologic therapy) often improves peripheral arthritis; sulfasalazine or TNF inhibitors first-line for peripheral joint disease, while axial disease is managed as for ankylosing spondylitis; avoid NSAIDs where possible given risk of exacerbating IBD; monitor both gut and joint activity concurrently as they may not always parallel each other; IL-17 inhibitors are avoided given risk of worsening IBD.
- Sarcoid arthropathy: NSAIDs first-line for acute sarcoid arthritis (often part of Löfgren syndrome with erythema nodosum and hilar lymphadenopathy), which is typically self-limiting; add corticosteroids for more persistent or destructive joint involvement; monitor for resolution, as Löfgren syndrome carries an excellent prognosis; distinguish acute self-limiting presentations from chronic sarcoid arthropathy, which may need steroid-sparing immunosuppression.
Dermatology
- Contact dermatitis: Identify and avoid the trigger allergen/irritant first-line, with topical corticosteroids for acute flares; emollients form the maintenance backbone in all cases; monitor for chronicity/lichenification with repeated exposure; patch testing helps confirm allergic contact dermatitis and identify specific allergens when the trigger is unclear.
- Bullous pemphigoid: Potent topical corticosteroids first-line (as effective as systemic steroids with fewer side effects in localised/moderate disease), escalating to systemic corticosteroids plus a steroid-sparing agent (azathioprine, mycophenolate) for widespread/refractory disease; monitor for infection of eroded skin and steroid-related complications, particularly in the elderly who predominate; doxycycline is a lower-toxicity alternative for milder disease.
- Molluscum contagiosum: Observation is first-line in immunocompetent children, as most lesions resolve spontaneously within months; physical destruction (cryotherapy, curettage) or topical agents (cantharidin, potassium hydroxide) for persistent, cosmetically bothersome, or widespread lesions; monitor for widespread/atypical presentation as a marker of underlying immunosuppression (e.g. HIV) in adults.
- Viral warts: Topical salicylic acid or cryotherapy first-line, with combination/repeated treatment often needed given modest single-session cure rates; escalate to more aggressive destructive methods (curettage, laser) for refractory lesions; monitor for spontaneous resolution, which occurs in the majority over 1-2 years, particularly in children; genital warts warrant screening for other STIs.
- Pediculosis (lice infestation): Topical pediculicide (permethrin or malathion) first-line, with a repeat application after 7-9 days to kill newly hatched lice; wet-combing as an adjunct/alternative; monitor for treatment failure/resistance, and treat close contacts to prevent reinfestation; environmental measures (washing bedding/clothing) have a supportive role.
- Squamous cell carcinoma (skin): Surgical excision with clear margins first-line, with Mohs micrographic surgery for high-risk sites (face) or high-risk histology; radiotherapy for non-surgical candidates or as adjuvant therapy for high-risk features (perineural invasion, positive margins); monitor for local recurrence and regional nodal metastasis, more common than with basal cell carcinoma; sun protection counselling to reduce further lesions.
- Seborrhoeic keratosis: Reassurance and observation first-line, as these are benign and require no treatment; cryotherapy or curettage for symptomatic (itchy, irritated) or cosmetically bothersome lesions; monitor for atypical features (rapid growth, bleeding, irregular pigmentation) which warrant biopsy to exclude melanoma, given occasional diagnostic overlap.
- Psoriasis (plaque, moderate-severe): Topical corticosteroid plus vitamin D analogue first-line for localised disease, escalating to phototherapy or systemic therapy (methotrexate, biologics) for moderate-severe/widespread disease; monitor for psoriatic arthritis (joint symptoms), cardiovascular risk factors, and liver/renal function on systemic agents; screen for latent TB and hepatitis before biologics.
- Atopic dermatitis (eczema): Emollients and topical corticosteroids first-line for flares, with topical calcineurin inhibitors as steroid-sparing options for sensitive sites; escalate to phototherapy or systemic immunomodulators (dupilumab, ciclosporin) for severe refractory disease; monitor for secondary bacterial/viral infection and growth in children on prolonged topical steroids; identify and avoid trigger factors (irritants, allergens).
- Acne vulgaris (moderate): Topical retinoid plus benzoyl peroxide or topical antibiotic first-line, escalating to oral antibiotics (doxycycline) for moderate inflammatory disease, and oral isotretinoin for severe/scarring or treatment-resistant disease; monitor liver function/lipids and pregnancy status (strict contraception required) on isotretinoin given teratogenicity; hormonal therapy (combined oral contraceptive, spironolactone) is an option in females.
- Cellulitis: Oral antibiotics (flucloxacillin or equivalent) first-line for uncomplicated disease, escalating to IV antibiotics for systemic upset, rapid progression, or failure of oral therapy; mark the margin to monitor progression; elevate the affected limb and manage any portal of entry (tinea pedis, wounds); consider necrotising fasciitis if pain is disproportionate to signs, which requires urgent surgical assessment.
- Impetigo: Topical antibiotic (fusidic acid/mupirocin) first-line for localised disease, escalating to oral antibiotics for widespread or bullous impetigo; monitor for spread given high contagiousness, and exclude from school/childcare until lesions crust/dry or 48h after starting treatment; hygiene measures reduce transmission to close contacts.
- Herpes simplex (recurrent labial/genital): Episodic oral aciclovir/valaciclovir at prodrome first-line for infrequent recurrences; suppressive daily antiviral therapy for frequent recurrences (>6/year) or to reduce transmission risk in genital disease; monitor for atypical/disseminated disease in immunocompromised patients requiring IV therapy; counsel on transmission risk and safe sex practices for genital disease.
- Scabies: Topical permethrin 5% applied to the whole body first-line, repeated after 7 days; treat all close contacts simultaneously regardless of symptoms to prevent reinfestation, and wash bedding/clothing; oral ivermectin for crusted (Norwegian) scabies or outbreak settings; monitor for persistent itch post-treatment (post-scabetic pruritus), which does not necessarily indicate treatment failure.
- Tinea corporis: Topical antifungal (terbinafine or azole) first-line, continued for 1-2 weeks beyond clinical resolution; escalate to oral antifungal (terbinafine) for extensive, recalcitrant, or immunocompromised-host disease; monitor for spread to close contacts and animal source if applicable (zoophilic dermatophytes); avoid topical corticosteroid monotherapy which can mask/worsen the infection (tinea incognito).
- Melanoma (localised): Wide local excision with margins guided by Breslow thickness is definitive first-line; sentinel lymph node biopsy offered for intermediate/high-risk tumours to stage disease; monitor with regular skin surveillance and clinical follow-up for recurrence/new primaries; adjuvant immunotherapy or targeted therapy (BRAF-mutant disease) considered for high-risk resected disease per current guidance.
- Basal cell carcinoma: Surgical excision with clear margins first-line, with Mohs micrographic surgery for high-risk sites (face) or recurrent tumours; topical therapy (imiquimod) or radiotherapy for superficial lesions or non-surgical candidates; monitor for local recurrence, which is the main risk (metastasis is rare); sun protection counselling given field cancerisation risk of further lesions.
- Squamous cell carcinoma (cutaneous): Surgical excision with clear margins first-line, with Mohs surgery for high-risk sites/histology; radiotherapy as adjuvant for high-risk features or as primary treatment in non-surgical candidates; monitor regional lymph nodes given metastatic potential exceeding basal cell carcinoma; immunosuppressed patients (transplant recipients) need closer surveillance given higher incidence and more aggressive behaviour.
- Urticaria (chronic): Non-sedating H1-antihistamine first-line, up-titrating to 4x standard dose before considering treatment failure; escalate to omalizumab or ciclosporin for refractory disease; monitor for angioedema/anaphylaxis features requiring emergency management; investigate for underlying autoimmune or physical triggers in atypical or treatment-refractory presentations.
- Stevens-Johnson syndrome/TEN: Immediate withdrawal of the causative drug is the single most important step, alongside supportive care in a burns/ICU setting (fluid, wound, and temperature management); consider IVIG or ciclosporin though evidence is mixed; monitor mucosal involvement (ocular, genital) closely given long-term scarring risk, with early ophthalmology input; mortality correlates with body surface area involved (SCORTEN score).
- Pemphigus vulgaris: Systemic corticosteroids first-line, with early addition of rituximab now favoured over steroid monotherapy given superior remission rates and steroid-sparing effect; monitor for secondary infection of denuded skin/mucosa and steroid-related complications; oral involvement is often the presenting and most refractory feature, requiring dedicated mouth care.
- Bullous pemphigoid: Topical or systemic corticosteroids, with steroid-sparing agents for chronic disease.
- Vitiligo: Topical corticosteroids or calcineurin inhibitors first-line for localised disease, escalating to phototherapy (narrowband UVB) for widespread disease; monitor treatment response, which can take months, and screen for associated autoimmune conditions (thyroid disease); camouflage and psychological support are important given cosmetic and quality-of-life impact.
- Alopecia areata: Intralesional or topical corticosteroids first-line for limited patchy disease; escalate to systemic immunosuppression (JAK inhibitors are increasingly used) for extensive or refractory disease; monitor for spontaneous regrowth, which is common in limited disease, and for progression to alopecia totalis/universalis; screen for associated autoimmune conditions (thyroid disease, vitiligo).
- Rosacea: Topical metronidazole or azelaic acid first-line for mild-moderate papulopustular disease, escalating to oral doxycycline for more severe/refractory disease; avoid triggers (sun exposure, alcohol, spicy food, heat) which vary by individual; monitor for ocular rosacea (dryness, blepharitis) needing separate management, and phymatous changes which may need laser/surgical treatment.
- Contact dermatitis (allergic): Allergen identification via patch testing and strict avoidance is central to management, alongside topical corticosteroids for acute flares; emollients maintain the skin barrier; monitor for chronic relapsing disease with ongoing occult exposure; occupational contact dermatitis may require workplace modification or, rarely, change of occupation.
- Contact dermatitis (irritant): Avoidance of the irritant and barrier protection (gloves, emollients) first-line, as no allergen is involved and patch testing is not diagnostic; topical corticosteroids for acute inflammation; monitor for chronicity with ongoing occupational/repeated exposure; distinguishing from allergic contact dermatitis (patch test negative) guides whether allergen avoidance counselling is needed.
- Seborrhoeic dermatitis: Topical antifungal (ketoconazole) shampoo/cream first-line, targeting the associated Malassezia yeast overgrowth; add low-potency topical corticosteroid for inflammatory flares; monitor for chronic relapsing course requiring intermittent maintenance therapy; more extensive/severe disease can be a marker of HIV infection, warranting consideration in atypical presentations.
- Lichen planus: Topical corticosteroids first-line for cutaneous/mucosal disease, escalating to systemic corticosteroids or other immunosuppression for widespread, erosive, or refractory disease; monitor oral lichen planus for malignant transformation risk with periodic review; identify and stop implicated drugs in lichenoid drug eruptions, which mimic idiopathic disease.
- Pityriasis rosea: Reassurance and observation first-line, as this is a self-limiting condition resolving over 6-8 weeks without treatment; symptomatic relief (emollients, antihistamines for itch) as needed; monitor for atypical presentation, and consider secondary syphilis as a differential in sexually active patients with a similar rash pattern.
- Erythema multiforme: Identify and treat/remove the trigger (most commonly HSV, sometimes drugs) first-line, with symptomatic treatment (antihistamines, topical corticosteroids) for the rash; suppressive antiviral therapy for recurrent HSV-associated disease; monitor for progression to more severe mucocutaneous involvement, distinguishing from Stevens-Johnson syndrome which carries a different prognosis and management intensity.
- Erythema nodosum: Treat the underlying cause (infection, sarcoidosis, IBD, drugs) first-line, alongside symptomatic management (NSAIDs, leg elevation, rest); monitor for resolution over weeks, as most cases are self-limiting once the trigger resolves; investigate for underlying systemic disease particularly if recurrent or associated with systemic symptoms.
- Pyoderma gangrenosum: Systemic corticosteroids first-line for significant disease, with ciclosporin as an alternative/steroid-sparing agent; avoid surgical debridement where possible, as pathergy can worsen ulceration; monitor for and treat the associated systemic disease (IBD, rheumatoid arthritis, haematological malignancy) present in a substantial proportion; wound care requires a specialised, non-aggressive approach.
- Hidradenitis suppurativa: Topical/oral antibiotics and lifestyle measures (weight loss, smoking cessation) first-line for mild disease, escalating to biologic therapy (adalimumab) for moderate-severe disease, and surgery (wide excision) for chronic scarred/tunnelling disease; monitor disease severity (Hurley staging) to guide escalation; psychological support is important given significant quality-of-life impact.
- Actinic keratosis: Cryotherapy for isolated lesions first-line, with field-directed topical therapy (5-fluorouracil, imiquimod, or photodynamic therapy) for multiple lesions/field change; monitor for progression to squamous cell carcinoma, the main rationale for treatment; sun protection counselling to prevent new lesions in this chronically sun-damaged population.
- Keloid scar: Intralesional corticosteroid injection first-line, often combined with silicone gel sheeting/pressure therapy; escalate to surgical excision combined with adjuvant therapy (steroid injection or radiotherapy) for refractory lesions, as excision alone carries high recurrence; monitor for recurrence, which is common; counsel at-risk individuals (darker skin types, family history) before elective procedures in keloid-prone sites.
- Molluscum contagiosum: Often self-limiting; cryotherapy or curettage for persistent/extensive lesions.
- Warts (verrucae): Topical salicylic acid or cryotherapy first-line.
- Herpetic whitlow: Oral aciclovir first-line, particularly if started early in the course; avoid incision and drainage, which can worsen/spread the infection and delay healing; monitor for recurrence, which is common given viral latency; healthcare workers should avoid direct patient contact during active lesions given transmission risk.
- Necrobiosis lipoidica: Topical or intralesional corticosteroids first-line for active inflammatory lesions; optimise glycaemic control given strong diabetes association, though this does not reliably improve the skin lesions; monitor for ulceration, a recognised complication requiring wound care; biopsy may be needed to exclude other granulomatous conditions if atypical.
- Erythroderma: Admission for supportive care (fluid/electrolyte balance, temperature regulation, infection surveillance) first-line given risk of high-output cardiac failure and sepsis; identify and treat the underlying cause (psoriasis, eczema, drug reaction, lymphoma); monitor fluid balance and skin barrier function closely; systemic therapy targeted to the underlying dermatosis once stabilised.
- Toxic epidermal necrolysis: Immediate causative drug withdrawal and transfer to a burns/ICU unit for supportive care is first-line, mirroring major burn management; IVIG or ciclosporin considered though evidence is mixed; monitor for sepsis and multi-organ involvement (ocular, mucosal, pulmonary) with early specialist input across disciplines; mortality is high and correlates with body surface area involved.
- Drug reaction with eosinophilia and systemic symptoms (DRESS): Immediate withdrawal of the causative drug first-line, with systemic corticosteroids for significant organ involvement; monitor liver, renal, and cardiac function closely given risk of delayed/relapsing multi-organ involvement over weeks; screen for HHV-6 reactivation, which is associated with the condition and relapse; recovery can be protracted with slow steroid tapering required.
- Fixed drug eruption: Identify and avoid the causative drug is definitive, as rechallenge reliably reproduces lesions at the same site; topical corticosteroids for symptomatic relief of the acute lesion; monitor for the generalised bullous variant, which can mimic more severe reactions and needs closer supportive care; patch testing at the lesion site can help confirm the causative agent.
- Cutaneous T-cell lymphoma (mycosis fungoides): Skin-directed therapy (topical corticosteroids, phototherapy) first-line for early-stage limited disease; escalate to systemic therapy (retinoids, interferon, or targeted agents) for advanced/refractory disease; monitor staging with skin examination and, in advanced disease, blood/nodal involvement; multidisciplinary review is recommended given the range of stage-adapted treatment options.
Ophthalmology
- Congenital cataract: Early surgical extraction (ideally within the first 6-8 weeks for dense unilateral cataract) is first-line to prevent irreversible amblyopia, followed by intensive optical correction and amblyopia therapy (patching); monitor visual development closely with paediatric ophthalmology follow-up, as the window for visual rehabilitation is narrow; screen for associated syndromic/metabolic causes (TORCH infections, galactosaemia) in bilateral cases.
- Dacryocystitis: Systemic antibiotics first-line for acute infection, with incision and drainage for abscess formation; definitive treatment of the underlying nasolacrimal duct obstruction (dacryocystorhinostomy) once acute infection has settled; monitor for orbital cellulitis as a complication of untreated/spreading infection; probing is first-line for congenital nasolacrimal duct obstruction in infants before considering DCR.
- Corneal foreign body/abrasion: Topical anaesthetic for examination, foreign body removal, and topical antibiotic first-line, with cycloplegic drops for pain from ciliary spasm; avoid topical anaesthetic for ongoing home use given corneal toxicity risk; monitor for infection (increasing pain, discharge) and healing at follow-up; contact lens wearers need cover for Pseudomonas given higher keratitis risk.
- Hypertensive retinopathy: Blood pressure control is the definitive treatment, as retinal changes are a marker of systemic disease rather than a target for direct ocular therapy; monitor retinal findings (grade of retinopathy) as a marker of hypertensive severity/end-organ damage and cardiovascular risk; screen for accelerated/malignant hypertension (grade 3-4 changes with papilloedema) requiring urgent blood pressure reduction and hospital assessment.
- Age-related macular degeneration: AREDS2 vitamin/mineral supplementation first-line for intermediate dry AMD to slow progression; anti-VEGF intravitreal injection for wet (neovascular) AMD, which requires prompt initiation to preserve vision; monitor with an Amsler grid for symptomatic changes prompting urgent review, and regular OCT imaging on anti-VEGF therapy; low vision aids/support for advanced disease with irreversible vision loss.
- Ptosis: Observation for mild, stable, non-amblyogenic ptosis first-line; urgent assessment and surgical correction for congenital ptosis obstructing the visual axis given amblyopia risk; investigate acquired ptosis for underlying cause (myasthenia gravis, Horner syndrome, third nerve palsy) before elective surgical correction; monitor visual development in children with any degree of visual axis occlusion.
- Exotropia (divergent squint): Observation for intermittent, well-controlled exotropia first-line; surgical correction (extraocular muscle surgery) for constant, large-angle, or progressively worsening deviation; monitor for amblyopia and stereopsis loss with orthoptic assessment; patching/optical correction addresses any associated refractive amblyopia before or alongside surgical planning.
- Ocular chemical injury: Immediate copious irrigation (before formal visual acuity testing) is the single most important step, continued until pH normalises; alkali burns cause more severe damage than acid and need especially prolonged irrigation; escalate to specialist ophthalmology assessment for grading (Roper-Hall) and management of ongoing epithelial defect/limbal ischaemia; monitor for glaucoma and corneal scarring as long-term sequelae requiring extended follow-up.
- Open-angle glaucoma: Topical prostaglandin analogue first-line to lower intraocular pressure, adding beta-blocker or other agents for inadequate control; escalate to laser trabeculoplasty or surgical trabeculectomy for progression despite maximal medical therapy; monitor intraocular pressure, optic disc appearance, and visual fields regularly to detect progression; screen first-degree relatives given hereditary risk.
- Acute angle-closure glaucoma: Immediate IV acetazolamide plus topical agents (pilocarpine, beta-blocker, alpha-agonist) to rapidly lower intraocular pressure is first-line, as this is an ophthalmic emergency threatening permanent vision loss; laser peripheral iridotomy is definitive once the acute attack settles, performed on the fellow eye prophylactically too; monitor intraocular pressure response closely and escalate to surgical iridectomy if laser is not accessible/effective.
- Cataract (visually significant): Phacoemulsification with intraocular lens implantation is definitive and highly effective, offered once visual impairment affects daily function/quality of life; no effective medical therapy delays progression; monitor for post-operative complications (endophthalmitis, posterior capsule opacification); biometry planning targets the desired post-operative refraction based on patient preference/lifestyle.
- Diabetic retinopathy (proliferative): Panretinal photocoagulation laser first-line to induce regression of neovascularisation; anti-VEGF intravitreal injection as an alternative/adjunct, particularly with concurrent macular oedema; vitrectomy for vitreous haemorrhage or tractional retinal detachment; monitor with regular retinal screening in all diabetics, and optimise glycaemic/blood pressure control which slows progression across all stages.
- Age-related macular degeneration (wet): Anti-VEGF intravitreal injection (loading doses then individualised regimen) first-line, started promptly as delay worsens visual outcomes; monitor with OCT imaging and Amsler grid self-monitoring for recurrence between injections; treatment is typically long-term/indefinite given high recurrence off therapy; combination or newer longer-acting agents are options for suboptimal responders.
- Retinal detachment: Urgent surgical repair (vitrectomy, scleral buckle, or pneumatic retinopexy depending on detachment type/location) is time-critical, particularly with macula-threatened or macula-off detachment where visual outcome worsens with delay; monitor for proliferative vitreoretinopathy as a cause of re-detachment; identify and treat retinal breaks in the fellow eye prophylactically if high-risk features are present.
- Central retinal artery occlusion: Immediate measures (ocular massage, IOP-lowering therapy) attempted if presenting within the narrow treatment window, though evidence for benefit is limited; treat as a stroke equivalent with urgent stroke/cardiovascular workup, as CRAO shares aetiology with cerebral stroke; monitor for giant cell arteritis in older patients (urgent ESR/CRP and temporal artery assessment) given need for emergency high-dose steroids if present; visual prognosis is generally poor once established.
- Bacterial keratitis: Intensive topical broad-spectrum antibiotics (often fortified) first-line, guided by corneal scrape culture in significant cases; escalate therapy/frequency for non-response or progression; monitor closely given risk of rapid progression to corneal perforation; contact lens wearers should stop lens use and are managed with Pseudomonas cover given higher risk of this aggressive organism.
- Bacterial conjunctivitis: Topical antibiotic (chloramphenicol) first-line, though many cases are self-limiting and antibiotics mainly shorten duration/prevent spread; hygiene measures reduce transmission; monitor for red flags (reduced vision, photophobia, significant pain) suggesting keratitis/more serious pathology requiring urgent ophthalmology referral rather than simple conjunctivitis management.
- Allergic conjunctivitis: Topical antihistamine/mast cell stabiliser first-line, alongside allergen avoidance where identifiable; cold compresses provide symptomatic relief; escalate to topical corticosteroids (short courses, ophthalmology-supervised) for severe/refractory disease given steroid-related glaucoma/cataract risk with prolonged use; monitor for atopic keratoconjunctivitis features in chronic severe disease, which carries corneal complication risk.
- Uveitis (anterior): Topical corticosteroids plus cycloplegic first-line to reduce inflammation and pain/prevent synechiae; investigate for an underlying systemic association (HLA-B27-related disease, sarcoidosis, infection) particularly with recurrent or bilateral disease; monitor intraocular pressure on steroid therapy and for complications (cataract, glaucoma, synechiae); escalate to systemic immunosuppression for chronic/recurrent or posterior segment involvement.
- Orbital cellulitis: IV broad-spectrum antibiotics first-line given risk of intracranial spread and vision loss; urgent surgical drainage for abscess formation, proptosis with visual compromise, or failure to improve on IV antibiotics; monitor visual acuity, colour vision, and pupillary response closely as markers of optic nerve compromise; distinguish from preseptal cellulitis, which is managed less aggressively as it lacks orbital involvement.
- Optic neuritis: High-dose IV corticosteroids considered to hasten visual recovery (though final visual outcome is largely unaffected) first-line for significant vision loss; investigate with MRI brain/orbits, as this often heralds multiple sclerosis, particularly with white matter lesions; monitor visual recovery, which is usually good even without treatment; discuss disease-modifying therapy referral if MRI suggests high conversion risk to MS.
- Retinopathy of prematurity: Regular screening examinations in at-risk premature infants first-line to detect treatable disease before irreversible damage; laser photocoagulation or anti-VEGF injection for threshold/high-risk pre-threshold disease; monitor for progression at defined screening intervals until vascularisation is complete or disease regresses; long-term follow-up for myopia, strabismus, and amblyopia even after successful treatment.
- Strabismus (childhood): Optical correction of any refractive error and amblyopia treatment (patching) first-line, as these often coexist and treating amblyopia is time-critical; surgical correction of the deviation for persistent/large-angle strabismus once optical/patching measures are optimised; monitor visual development and binocular function; early assessment is important as the window for reversing amblyopia narrows with age.
- Corneal abrasion: Topical antibiotic ointment/drops and analgesia first-line, with most abrasions healing within 24-48h; avoid topical anaesthetic for ongoing use given delayed healing/toxicity risk; monitor for infection and non-healing, particularly in contact lens wearers who need Pseudomonas cover; bandage contact lens or patching has limited evidence and is used selectively.
- Chemical eye injury (alkali): Immediate copious irrigation before any other assessment is the critical first step, continued until pH returns to normal (typically 7.0); alkali injury penetrates deeper than acid and requires more aggressive/prolonged irrigation; escalate to specialist ophthalmology management (topical steroids, ascorbate, tectonic support) for significant limbal/corneal involvement; monitor for delayed complications (glaucoma, corneal melt, symblepharon) over weeks to months.
- Hyphaema (traumatic): Bed rest with head elevation and eye shield first-line to reduce rebleed risk, avoiding NSAIDs/aspirin which increase bleeding; monitor intraocular pressure closely (raised IOP is common and needs treatment) and for rebleeding, typically within the first 3-5 days; escalate to surgical evacuation for uncontrolled IOP, corneal blood staining, or non-clearing hyphaema; sickle cell status should be checked given higher complication risk in sickle trait/disease.
- Globe rupture (traumatic): Immediate protection with a rigid shield (avoiding any pressure on the globe) and urgent surgical repair is definitive, as this is a vision- and globe-threatening emergency; avoid further examination/manipulation that could extrude intraocular contents; broad-spectrum IV antibiotics and tetanus prophylaxis alongside; monitor for endophthalmitis and sympathetic ophthalmia risk in the fellow eye with severe injury.
- Endophthalmitis (post-surgical): Urgent intravitreal antibiotic injection (with vitreous tap for culture) is first-line and time-critical, as delay significantly worsens visual outcome; escalate to vitrectomy for severe presentation (light perception vision or worse); monitor visual acuity and inflammation response closely, often requiring repeat intravitreal dosing; this is an ophthalmic emergency requiring same-day specialist management.
- Dacryocystitis (acute): Systemic antibiotics first-line for the acute infective episode, with drainage of any associated abscess; definitive surgical correction (dacryocystorhinostomy) of the underlying duct obstruction deferred until acute inflammation resolves; monitor for spread to orbital cellulitis, particularly in more severe or delayed-presentation cases.
- Chalazion: Warm compresses and lid massage first-line, as many resolve spontaneously over weeks; intralesional corticosteroid injection or surgical incision/curettage for persistent lesions; monitor for recurrence and, in atypical or recurrent unilateral lesions in older patients, consider biopsy to exclude sebaceous gland carcinoma, an important mimic.
- Blepharitis: Lid hygiene (warm compresses, lid margin cleaning) first-line as the mainstay of chronic management; add topical antibiotic or short-course topical steroid for acute exacerbations; monitor for associated dry eye and meibomian gland dysfunction requiring concurrent management; this is typically a chronic relapsing condition requiring ongoing maintenance rather than a curable one-off treatment.
- Entropion/ectropion: Lubrication and taping as temporising measures first-line while surgery is arranged; definitive surgical correction (lid tightening/repositioning procedures) is the mainstay for symptomatic disease; monitor for corneal exposure/abrasion complications, particularly with entropion where lashes rub the cornea, which can threaten vision if prolonged.
- Pterygium (symptomatic): Lubricants and sun protection (UV-blocking sunglasses) first-line for mild irritation; surgical excision with conjunctival autograft for visually significant, rapidly growing, or persistently symptomatic pterygium; monitor for recurrence, which is reduced but not eliminated by autografting compared to bare sclera technique; astigmatism/visual axis involvement is an indication to expedite surgery.
- Keratoconus: Spectacle or rigid contact lens correction first-line for visual rehabilitation in early/stable disease; corneal collagen cross-linking to halt progression in documented progressive disease, ideally before significant thinning; corneal transplantation (DALK or penetrating keratoplasty) for advanced disease with contact lens intolerance or central scarring; monitor corneal topography serially to detect progression warranting cross-linking.
- Optic disc oedema (papilloedema): Urgent neuroimaging to identify and treat the underlying cause (raised intracranial pressure from mass lesion, venous sinus thrombosis, idiopathic intracranial hypertension) is first-line, as papilloedema itself is a sign rather than a primary diagnosis; monitor visual fields and acuity closely, as prolonged untreated papilloedema causes irreversible optic atrophy; lumbar puncture with opening pressure once mass lesion excluded, both diagnostic and sometimes therapeutic in IIH.
- Retinal vein occlusion (central): Anti-VEGF intravitreal injection first-line for macular oedema with vision loss; investigate for underlying risk factors (hypertension, glaucoma, hyperviscosity states) and manage these concurrently; monitor for neovascular complications (neovascular glaucoma) requiring panretinal photocoagulation; visual prognosis is variable and depends on ischaemic versus non-ischaemic subtype.
- Amblyopia: Correction of the underlying cause (refractive error, strabismus, or visual deprivation such as cataract) first-line, followed by occlusion therapy (patching the better eye) to stimulate the amblyopic eye; monitor visual acuity response to patching regularly, adjusting patching regimen accordingly; treatment is most effective when started early, as efficacy declines with increasing age at presentation.
- Congenital cataract: Early surgical removal to prevent amblyopia.
- Thyroid-associated orbitopathy (compressive): Manage thyroid dysfunction and smoking cessation first-line (smoking significantly worsens orbitopathy severity/progression); high-dose IV corticosteroids for active moderate-severe inflammatory disease, with orbital decompression surgery for sight-threatening compressive optic neuropathy; monitor visual acuity, colour vision, and optic nerve function closely for signs of compression requiring urgent decompression; strabismus/eyelid surgery is deferred until the disease is quiescent.
- Orbital fracture (blowout): Conservative management (ice, avoid nose-blowing, analgesia) first-line for fractures without significant entrapment or enophthalmos; urgent surgical repair for muscle entrapment with the oculocardiac reflex (bradycardia, nausea on gaze) or significant diplopia/enophthalmos; monitor for infraorbital nerve numbness and diplopia on serial examination; CT imaging defines fracture extent and guides the urgency of surgical referral.
ENT
- Tympanic membrane perforation: Watchful waiting first-line, as most traumatic/post-infective perforations heal spontaneously within weeks; keep the ear dry and avoid topical aminoglycosides (ototoxic through a perforation) unless infected; escalate to surgical repair (myringoplasty) for perforations persisting beyond 6-12 weeks or causing recurrent infection/significant hearing loss; monitor hearing and for cholesteatoma development in chronic perforations.
- Sensorineural hearing loss: Identify and treat any reversible cause (ototoxic drug withdrawal, treat underlying infection) first-line, though most causes are irreversible; hearing aids or cochlear implantation (for severe-profound loss with inadequate hearing aid benefit) for rehabilitation; monitor progression with serial audiometry, particularly important in sudden or asymmetric loss to exclude a retrocochlear cause (vestibular schwannoma) with MRI.
- Adenoid hypertrophy: Watchful waiting first-line in mild cases, as adenoids often regress with age; adenoidectomy for significant nasal obstruction, recurrent otitis media with effusion, or obstructive sleep apnoea features; monitor for associated conductive hearing loss and speech/behavioural impact; assess for coexisting tonsillar hypertrophy, as combined adenotonsillectomy is often performed together for sleep-disordered breathing.
- Laryngitis: Voice rest, hydration, and avoidance of irritants (smoking) first-line, as most cases are viral and self-limiting; antibiotics only for evidence of bacterial superinfection or in the immunocompromised; monitor for persistent hoarseness beyond 3 weeks, which warrants laryngoscopy to exclude malignancy, particularly in smokers/heavy alcohol users.
- Vocal cord nodules: Voice therapy (speech and language therapy) first-line, addressing the vocal misuse/overuse pattern that causes them, with good response in most cases; surgical excision reserved for persistent nodules despite adequate voice therapy; monitor vocal quality and adherence to therapy; occupational voice users (singers, teachers) benefit from targeted vocal hygiene education to prevent recurrence.
- Nasopharyngeal carcinoma: Radiotherapy (with concurrent chemotherapy for locally advanced disease) is first-line given radiosensitivity and difficult surgical access; monitor treatment response with imaging and EBV DNA levels (a useful biomarker in EBV-associated disease) where available; screen for and manage radiotherapy-related complications (xerostomia, hypothyroidism); regional variation in incidence (endemic in parts of East/Southeast Asia) should raise suspicion in at-risk populations presenting with neck mass/nasal symptoms.
- Sialadenitis: IV or oral antibiotics first-line for acute bacterial sialadenitis, alongside hydration, sialagogues (to stimulate salivary flow), and gland massage; escalate to surgical drainage for abscess formation; monitor for an obstructing stone as the underlying cause, particularly with recurrent episodes, which may need duct exploration/removal.
- Benign paroxysmal positional vertigo: Epley (or appropriate canalith repositioning) manoeuvre is first-line and often curative in a single session; vestibular sedatives have limited role and may delay central compensation if used long-term; monitor for recurrence, which is common and may need repeat manoeuvres; exclude central causes (posterior circulation stroke) if atypical features (other neurological signs, non-fatiguing nystagmus) are present.
- Acute otitis media: Analgesia first-line with a watchful-waiting approach for 48-72h in most children given high spontaneous resolution rates; antibiotics (amoxicillin) for children under 2 with bilateral disease, those with otorrhoea, or if symptoms persist/worsen; monitor for complications (mastoiditis, persistent effusion) and recurrent episodes which may warrant grommet insertion.
- Chronic suppurative otitis media: Aural toilet plus topical antibiotic (quinolone, safe with a perforated drum) first-line for active discharge; definitive surgical management (myringoplasty/tympanoplasty, or mastoidectomy for cholesteatoma) once infection is controlled; monitor for cholesteatoma, which requires more aggressive surgical management given erosive/destructive potential; avoid ototoxic topical agents (aminoglycosides) through a perforation for prolonged periods where alternatives exist.
- Acute tonsillitis (bacterial): Analgesia and supportive care first-line, as most cases are viral; penicillin (or macrolide if allergic) for confirmed/suspected group A streptococcal infection, guided by clinical scoring (Centor/FeverPAIN); monitor for peritonsillar abscess (quinsy) as a complication; recurrent tonsillitis meeting frequency criteria may warrant tonsillectomy referral.
- Peritonsillar abscess (quinsy): Needle aspiration or incision and drainage plus IV antibiotics is first-line and usually curative; monitor airway patency closely given risk of obstruction with large abscesses; interval tonsillectomy considered for recurrent quinsy; steroids may hasten symptomatic improvement as an adjunct to drainage and antibiotics.
- Acute sinusitis (bacterial): Analgesia, nasal saline irrigation, and intranasal corticosteroids first-line, as most acute sinusitis is viral and self-limiting; antibiotics reserved for symptoms persisting beyond 10 days, severe symptoms, or a 'double-sickening' pattern suggesting bacterial superinfection; monitor for orbital or intracranial complications (periorbital swelling, severe headache, neurological signs) requiring urgent imaging and escalation.
- Epistaxis (anterior): Direct pressure (pinching the soft cartilaginous part of the nose) for 10-15 minutes first-line, with topical vasoconstrictor/cautery for persistent bleeding; nasal packing if cautery fails; monitor blood pressure and for underlying coagulopathy/anticoagulant use in recurrent or difficult-to-control bleeds; most anterior bleeds arise from Little's area and respond well to first-line measures.
- Epistaxis (posterior, severe): Posterior nasal packing (balloon or ribbon gauze) plus resuscitation first-line, given greater blood loss and airway risk than anterior bleeds; escalate to sphenopalatine artery ligation or embolisation for bleeding refractory to packing; monitor haemoglobin and haemodynamics closely, admitting for observation given aspiration and hypoxia risk with posterior packs; correct any coagulopathy concurrently.
- Obstructive sleep apnoea (paediatric): Adenotonsillectomy is first-line and highly effective when tonsillar/adenoidal hypertrophy is the cause, which is the case in most paediatric OSA; monitor growth, behaviour, and cardiovascular signs (right heart strain in severe untreated disease); polysomnography confirms diagnosis/severity and guides urgency of intervention; CPAP is reserved for those with persistent OSA post-surgery or when surgery is contraindicated.
- Vocal cord nodules: Voice therapy first-line; surgery reserved for refractory cases.
- Laryngeal carcinoma (early): Radiotherapy or transoral laser surgery, both with comparable cure rates and organ (voice) preservation, are first-line for early-stage glottic disease; monitor with regular laryngoscopic surveillance for recurrence; smoking and alcohol cessation counselling is essential given shared risk factors and impact on treatment outcomes; voice outcomes should be discussed when choosing between modalities.
- Head and neck squamous cell carcinoma (locally advanced): Concurrent chemoradiotherapy or surgery followed by adjuvant (chemo)radiotherapy first-line, chosen based on site/resectability and functional considerations; monitor treatment response and for treatment-related toxicity (mucositis, xerostomia, dysphagia) requiring supportive care (feeding tube, speech/swallow therapy); multidisciplinary team input is essential given the complexity of functional/cosmetic trade-offs.
- Foreign body in the ear/nose/airway: Prompt removal under direct visualisation (or endoscopically for airway/deep foreign bodies) is first-line, avoiding blind instrumentation which risks pushing objects deeper; airway foreign bodies causing respiratory distress require emergency management (back blows/Heimlich, or rigid bronchoscopy); monitor for complications (mucosal injury, infection) and button battery ingestion specifically requires urgent removal given rapid tissue necrosis risk.
- Meniere's disease: Low-salt diet and betahistine first-line for symptom control between attacks; intratympanic steroid or gentamicin injection for refractory vertigo attacks despite medical therapy; monitor hearing (typically fluctuating, progressing to permanent loss over time) and vertigo frequency/severity; surgical options (endolymphatic sac surgery, labyrinthectomy) reserved for severe refractory disease given more definitive but higher-risk nature.
- Sudden sensorineural hearing loss: High-dose oral (or intratympanic) corticosteroids started as soon as possible (ideally within 2 weeks) is first-line, as this is an otological emergency where delay reduces recovery chance; urgent MRI to exclude vestibular schwannoma as an underlying cause; monitor hearing recovery with serial audiometry; most cases remain idiopathic despite investigation.
- Nasal septal deviation (symptomatic): Nasal saline and intranasal corticosteroids first-line for mild obstructive symptoms; septoplasty for significant deviation causing persistent obstruction refractory to medical therapy; monitor symptom improvement and nasal airflow; assess for coexisting rhinitis/polyps contributing to obstruction, as these need separate/concurrent management.
- Nasal polyposis: Intranasal (and short-course oral) corticosteroids first-line, often with long-term maintenance given high recurrence; escalate to biologic therapy (anti-IL-4/13, anti-IgE) or endoscopic sinus surgery for refractory disease; monitor symptom control and screen for associated asthma and aspirin-exacerbated respiratory disease (Samter's triad); recurrence is common even after surgery without ongoing medical maintenance therapy.
- Juvenile nasopharyngeal angiofibroma: Surgical excision (often with pre-operative embolisation to reduce intraoperative bleeding given high vascularity) is first-line and curative for resectable disease; radiotherapy reserved for unresectable/recurrent disease; monitor for recurrence with surveillance imaging; this occurs almost exclusively in adolescent males, an important diagnostic clue for recurrent unilateral epistaxis in this demographic.
- Nasopharyngeal carcinoma: Chemoradiotherapy as primary treatment.
- Salivary gland stone (sialolithiasis): Conservative measures (hydration, sialagogues, gland massage, warm compresses) first-line for small distal stones, which may pass spontaneously; sialendoscopy or surgical removal for larger/proximal stones or recurrent obstruction; monitor for secondary infection (sialadenitis) requiring antibiotics; gland excision reserved for recurrent symptomatic stones unresponsive to duct-preserving approaches.
- Parotitis (bacterial): IV antibiotics (covering Staphylococcus aureus) plus hydration and sialagogues first-line; surgical drainage for abscess formation; monitor for risk factors (dehydration, poor oral hygiene, post-surgical) and address these to prevent recurrence; distinguish from viral parotitis (mumps), which is managed supportively and has different infection control implications.
- Pleomorphic adenoma (parotid): Superficial or partial parotidectomy with a cuff of normal tissue (avoiding enucleation, which risks recurrence) is definitive; monitor for facial nerve function post-operatively, as the nerve runs through the gland and is at risk during surgery; monitor for recurrence, and note the (rare but recognised) risk of malignant transformation in long-standing untreated lesions, supporting surgical excision even though the tumour is benign.
- Cholesteatoma: Surgical excision (mastoidectomy) is definitive, as cholesteatoma is locally destructive and does not resolve with medical therapy alone; topical antibiotics may control secondary infection/discharge pre-operatively; monitor for recurrence, which requires long-term follow-up given risk of residual/recurrent disease; untreated disease risks progressive hearing loss, facial nerve palsy, and intracranial complications (abscess, meningitis).
- Otosclerosis: Hearing aids first-line for symptomatic conductive hearing loss, as a non-surgical option; stapedectomy/stapedotomy offers definitive surgical correction with good hearing outcomes for suitable candidates; monitor hearing progression, which is often bilateral and progressive; sodium fluoride has historically been used to slow progression though evidence is limited and it is now rarely used.
- Mastoiditis (acute): IV antibiotics first-line, with urgent surgical drainage (cortical mastoidectomy) for abscess formation, subperiosteal collection, or failure to improve on IV antibiotics; monitor closely for intracranial complications (meningitis, sigmoid sinus thrombosis, brain abscess) given proximity, which mandate imaging if there are red flag features; this typically arises as a complication of inadequately treated acute otitis media.
- Retropharyngeal abscess: IV antibiotics first-line for small abscesses/cellulitis, with urgent surgical drainage for larger collections or airway compromise; monitor airway closely given risk of sudden obstruction, particularly in young children where this is more common; imaging (CT neck) confirms extent and guides the decision for surgical versus medical management alone.
- Ludwig's angina: IV broad-spectrum antibiotics plus urgent airway assessment/securing (often requiring awake fibreoptic intubation or surgical airway) is first-line, as rapid bilateral submandibular space swelling can cause life-threatening airway obstruction; surgical drainage for abscess formation or failure to improve; monitor airway continuously given the rapidity with which obstruction can develop; dental source control (extraction of the causative tooth) is often needed once stabilised.
- Laryngomalacia (infant): Reassurance and observation first-line, as most cases are mild and resolve spontaneously by 12-18 months as laryngeal cartilage matures; escalate to supraglottoplasty for severe disease with feeding difficulty, failure to thrive, or apnoeic episodes; monitor growth and respiratory status, as these guide the need for surgical intervention; positional/feeding advice can help mild-moderate symptoms.
- Vocal cord paralysis (unilateral): Voice therapy first-line, as many patients compensate adequately, particularly with unilateral paralysis; escalate to injection medialisation or surgical thyroplasty for persistent significant dysphonia/aspiration; investigate the underlying cause (thyroid surgery, malignancy, idiopathic) with imaging of the nerve's course; monitor for aspiration risk, particularly relevant with bilateral involvement which additionally threatens the airway.
- Tinnitus (subjective, chronic): Reassurance, hearing aid provision (if hearing loss present), and sound therapy/tinnitus retraining first-line, as most chronic subjective tinnitus has no curable underlying cause; cognitive behavioural therapy for tinnitus-related distress; monitor for red flags (unilateral pulsatile tinnitus, asymmetric hearing loss) warranting imaging to exclude vestibular schwannoma or vascular cause; manage coexisting anxiety/depression, which commonly amplifies perceived severity.
- Presbycusis: Hearing aid fitting first-line once hearing loss impacts communication/quality of life, as this is a progressive age-related sensorineural process without a reversible cause; monitor hearing with serial audiometry to track progression and guide aid adjustment; address associated social isolation and cognitive impact, given recognised links between untreated hearing loss and cognitive decline.
- Otitis externa: Topical antibiotic-corticosteroid combination drops first-line, with aural toilet (cleaning debris) to improve drug penetration and speed resolution; keep the ear dry during treatment and avoid cotton buds/instrumentation; monitor for progression to malignant otitis externa in diabetic/immunocompromised patients, which needs a markedly different, more aggressive approach.
- Malignant (necrotising) otitis externa: Prolonged IV/oral antipseudomonal antibiotics (often 6-8 weeks or longer) first-line, as this is an aggressive skull-base osteomyelitis typically in diabetic or immunocompromised patients; surgical debridement for progression or abscess despite antibiotics; monitor with inflammatory markers and imaging (CT/MRI, or nuclear medicine scanning) to track disease resolution, as clinical appearance can lag; cranial nerve involvement (particularly facial nerve) indicates more extensive disease and worse prognosis.
Orthopaedics & Trauma
- Elbow fracture-dislocation: Closed reduction under sedation first-line for simple dislocations, followed by early mobilisation once stable; open reduction and internal fixation (with ligament/capsule repair) for fracture-dislocations with instability (e.g. terrible triad injury); monitor neurovascular status closely before and after reduction given ulnar/median nerve and brachial artery proximity; splint in a position avoiding stiffness (avoid prolonged immobilisation beyond 1-2 weeks) as elbow stiffness is the dominant long-term complication.
- Wrist and hand fractures: Closed reduction and cast immobilisation first-line for stable, minimally displaced fractures; surgical fixation (K-wires, plates, or external fixation) for unstable, intra-articular, or open injuries; monitor for compartment syndrome and median nerve function (acute carpal tunnel) in high-energy wrist injuries; in children, remodelling potential allows more angulation to be accepted, reducing the threshold for non-operative management.
- Spinal compression fracture (traumatic): Analgesia and bracing first-line for stable fractures without neurological compromise; escalate to surgical stabilisation (instrumented fusion) for unstable fracture patterns, significant kyphosis, or neurological deficit; monitor neurological status serially and reassess stability with flexion-extension imaging once acute pain settles; in osteoporotic compression fractures, consider vertebroplasty/kyphoplasty for refractory pain and address underlying bone health.
- Spondylolisthesis: Physiotherapy (core stabilisation) and activity modification first-line for low-grade, asymptomatic-to-mild disease; surgical fusion (with or without decompression) for progressive slip, high-grade disease, or neurological compromise; monitor slip progression with serial imaging in growing adolescents; avoid high-impact sports until symptoms and slip grade are controlled.
- Knee dislocation: Emergency reduction is time-critical, followed immediately by careful assessment for popliteal vascular injury (ankle-brachial index, CT angiography if abnormal) given high risk of limb-threatening ischaemia; staged ligament reconstruction (multi-ligament repair) once swelling settles; monitor distal pulses and compartments closely for 24-48 hours post-reduction even with a normal initial vascular exam, as delayed vascular injury can occur; low threshold for vascular surgery referral.
- Tuberculosis of bone and joint: Standard anti-TB therapy (typically extended to 6-12 months for osteoarticular disease) as first-line, with surgical debridement reserved for abscess, significant deformity, or neurological compromise (Pott's disease with cord compression); monitor clinical and radiological response, and liver function on therapy; screen for HIV and multidrug-resistant TB in poor responders; joint destruction may still need reconstructive surgery after infection is controlled.
- Septic arthritis: Emergency joint washout/drainage (arthroscopic or open) plus empirical then targeted IV antibiotics is first-line, as delay risks rapid cartilage destruction; escalate to repeat washout if clinical response is inadequate at 48-72 hours; monitor inflammatory markers and clinical response serially, with a low threshold to re-image/re-aspirate; in prosthetic joint infection, staged revision arthroplasty is usually required rather than washout alone.
- Diabetic foot ulcer: Glycaemic optimisation, offloading (total contact casting), and regular debridement first-line; escalate to targeted antibiotics for infected ulcers (guided by deep tissue culture, not swab) and vascular assessment/revascularisation if ischaemic component present; monitor for osteomyelitis with imaging (MRI) if the ulcer probes to bone; amputation is reserved for extensive necrosis, uncontrolled sepsis, or failed revascularisation; multidisciplinary foot clinic follow-up reduces recurrence.
- Open fracture (Gustilo-Anderson I-II): Urgent IV antibiotics (within an hour of injury) and tetanus prophylaxis first-line, followed by thorough surgical debridement and irrigation within 24 hours, with fracture stabilisation appropriate to the fracture pattern; monitor for infection and compartment syndrome; delay definitive soft-tissue closure if contamination is significant, favouring staged management.
- Meniscal tear: Physiotherapy and activity modification first-line for degenerative or stable peripheral tears, particularly in older patients where surgery offers limited benefit; arthroscopic partial meniscectomy or repair for symptomatic mechanical tears (locking, giving way) in younger patients, favouring repair over resection where the tear is repairable to preserve meniscal function; monitor for early osteoarthritis progression after meniscectomy given loss of shock absorption.
- Open fracture (Gustilo-Anderson III): Urgent broad-spectrum IV antibiotics, aggressive debridement, and provisional external fixation first-line given high contamination/soft-tissue loss; escalate to staged definitive fixation and flap coverage once the wound is clean, often requiring plastic surgery input; monitor closely for compartment syndrome and deep infection; amputation may be considered early in mangled-extremity scores predicting non-salvageable limbs.
- Closed long bone fracture (displaced): Reduction with internal fixation (intramedullary nailing or plating) or external fixation first-line depending on fracture pattern, soft-tissue condition, and patient factors; monitor for compartment syndrome in the acute period and for delayed union/non-union on serial imaging; in polytrauma, damage-control external fixation followed by delayed definitive fixation reduces complication risk in the physiologically unstable patient.
- Hip fracture (elderly): Early surgical fixation (intramedullary nail/sliding hip screw) or arthroplasty (hemiarthroplasty/total hip replacement, guided by fracture pattern and pre-injury mobility) within 24-48 hours is first-line to enable early mobilisation and reduce mortality; escalate to orthogeriatric co-management for perioperative optimisation; monitor for delirium, VTE, and pressure injury proactively; delay beyond 48 hours without medical justification is associated with worse outcomes.
- Compartment syndrome: Emergency fasciotomy is definitive and time-critical (ideally within 6 hours of onset) once diagnosed clinically or by compartment pressure measurement; monitor the wound for delayed primary closure or skin grafting once swelling resolves; avoid elevating the limb above heart level (worsens perfusion) and avoid tight dressings/casts pending fasciotomy; missed diagnosis risks irreversible muscle necrosis and limb loss.
- Septic arthritis (native joint): Urgent surgical washout plus targeted IV antibiotics (initially empirical covering Staphylococcus aureus, narrowed to culture) is first-line; escalate to repeat arthroscopic or open washout if clinical/inflammatory markers fail to improve within 48-72 hours; monitor joint function and inflammatory markers serially; consider gonococcal arthritis in sexually active young adults, which often responds to antibiotics alone without repeat washout.
- Osteomyelitis (acute): Prolonged targeted IV antibiotics (typically 4-6 weeks, often with oral step-down) first-line, with surgical debridement reserved for abscess, sequestrum, or failure of medical therapy; monitor inflammatory markers and clinical response, with imaging (MRI) to assess extent and guide surgical planning; in children, haematogenous osteomyelitis usually responds well to antibiotics alone if treated early, whereas adults and diabetics more often need surgical debridement.
- Rotator cuff tear (full-thickness): Physiotherapy first-line for partial/degenerative tears in lower-demand or older patients; surgical repair (arthroscopic or open) for acute traumatic full-thickness tears in active individuals, ideally within weeks to limit muscle retraction and fatty infiltration; monitor functional recovery post-repair with structured rehabilitation; massive irreparable tears in the elderly may be managed with reverse total shoulder arthroplasty if pain/function are significantly impaired.
- Anterior cruciate ligament rupture: Physiotherapy (quadriceps strengthening, neuromuscular training) first-line for low-demand patients or those willing to modify activity; surgical reconstruction for active/high-demand patients or those with instability affecting daily function; monitor for meniscal/chondral injury at the time of reconstruction, as concurrent injuries affect long-term outcome; delaying surgery for a period of pre-habilitation improves post-operative range of motion.
- Achilles tendon rupture: Functional bracing in equinus with early controlled mobilisation is an effective non-operative option with re-rupture rates approaching surgical repair in appropriately selected patients; surgical repair preferred for active individuals, delayed presentation, or re-rupture; monitor for re-rupture and wound complications (higher with open repair); early weight-bearing and structured rehabilitation improve functional outcomes regardless of treatment choice.
- Carpal tunnel syndrome: Wrist splinting (especially night-time) and corticosteroid injection first-line for mild-moderate disease; surgical decompression for refractory symptoms, significant sensory loss, or thenar wasting; monitor nerve conduction studies to grade severity and guide urgency of surgery; pregnancy-associated carpal tunnel syndrome often resolves post-partum and can usually be managed conservatively.
- Frozen shoulder (adhesive capsulitis): Physiotherapy and intra-articular corticosteroid injection first-line, particularly effective in the early painful "freezing" phase; capsular release (arthroscopic or manipulation under anaesthesia) for refractory disease persisting beyond 6-12 months; monitor range of motion serially, as the condition is often self-limiting over 1-3 years; diabetics have higher incidence and slower resolution, warranting earlier/more aggressive intervention.
- Scoliosis (adolescent idiopathic, progressive): Bracing first-line for moderate curves (typically 25-40°) in a skeletally immature patient to prevent progression; surgical correction (instrumented spinal fusion) for severe curves (>45-50°) or progression despite bracing; monitor curve progression with serial standing radiographs during growth spurts (Risser staging); screen for underlying neuromuscular or syndromic causes if atypical curve pattern or early onset.
- Developmental dysplasia of the hip: Pavlik harness first-line in infants under 6 months with reducible dysplasia; closed or open reduction with spica casting for failed harness treatment or late-presenting cases; monitor with serial ultrasound (under 6 months) or X-ray (over 6 months) to confirm reduction and acetabular development; delayed diagnosis increases risk of avascular necrosis and long-term osteoarthritis, underscoring the value of newborn screening.
- Slipped capital femoral epiphysis: Urgent surgical pinning (in-situ fixation) is first-line to prevent further slippage once diagnosed, regardless of severity, given risk of avascular necrosis with delay; monitor the contralateral hip closely, as bilateral involvement is common (prophylactic pinning is considered in high-risk endocrine/metabolic disorders); avoid weight-bearing until stabilised; screen for underlying endocrinopathy (hypothyroidism, growth hormone disorders) in atypical age or weight presentations.
- Osteosarcoma: Neoadjuvant chemotherapy followed by limb-sparing surgical resection with wide margins is first-line where feasible; amputation reserved for tumours not amenable to limb salvage (extensive neurovascular involvement); monitor chemotherapy response histologically (percentage necrosis) to guide adjuvant chemotherapy intensity and prognosis; screen for pulmonary metastases at diagnosis and on surveillance, as the lung is the dominant site of spread.
- Bone metastases with pain: Radiotherapy first-line for localised painful metastases; surgical stabilisation (prophylactic fixation) for impending pathological fracture (per Mirels' scoring) or actual fracture; monitor for hypercalcaemia and further skeletal-related events; bisphosphonates/denosumab reduce skeletal-related event frequency and are used alongside definitive local treatment; multidisciplinary input balances life expectancy against surgical morbidity.
- Spinal stenosis (lumbar, symptomatic): Physiotherapy and analgesia first-line, with epidural steroid injection as an adjunct for radicular pain; decompressive laminectomy (with or without fusion) for refractory neurogenic claudication or progressive neurological deficit; monitor for cauda equina symptoms (saddle anaesthesia, bladder/bowel dysfunction) which mandate urgent surgical referral; in the elderly, weigh surgical risk against expected functional benefit.
- Herniated lumbar disc with radiculopathy: Conservative management (analgesia, physiotherapy, activity modification) first-line, as most cases improve within 6-12 weeks; discectomy for persistent radicular pain despite conservative therapy beyond 6-12 weeks, or for progressive/severe neurological deficit; monitor for cauda equina syndrome red flags requiring emergency MRI and decompression; epidural steroid injection can be considered as an interim measure.
- Clavicle fracture (midshaft, minimally displaced): Sling immobilisation first-line, as most heal without surgery; surgical fixation (plating) for significant displacement, shortening (>2cm), or comminution given higher non-union/malunion risk with these patterns; monitor for neurovascular compromise (subclavian vessels, brachial plexus) at presentation; early gentle mobilisation once pain allows reduces stiffness.
- Scaphoid fracture: Cast immobilisation first-line for non-displaced, stable fractures; surgical fixation (percutaneous screw) for displaced fractures, proximal pole fractures, or those at high non-union risk (e.g. athletes wanting faster return); monitor with repeat imaging (including MRI/CT if X-ray equivocal) given the risk of missed fracture and subsequent avascular necrosis of the proximal pole due to retrograde blood supply.
- Colles' fracture: Closed reduction and cast immobilisation first-line for stable, acceptably aligned fractures; surgical fixation (volar locking plate) for unstable/displaced fractures or those failing to maintain reduction in cast; monitor for median nerve compression (acute carpal tunnel) and, in the longer term, for malunion affecting wrist function; in elderly low-demand patients, some residual deformity is often accepted given lower functional requirements.
- Supracondylar humerus fracture (paediatric): Closed reduction and percutaneous pinning first-line for displaced (Gartland type II-III) fractures, with careful neurovascular monitoring given proximity of the brachial artery and median/radial/ulnar nerves; open reduction if closed reduction fails or the vessel is entrapped; monitor the pulse and hand perfusion closely post-reduction, as a pink pulseless hand requires urgent vascular reassessment; compartment syndrome is a recognised complication requiring vigilance.
- Ankle fracture (unstable): Surgical open reduction and internal fixation is first-line for unstable patterns (bimalleolar, trimalleolar, or with syndesmotic disruption); monitor soft-tissue swelling before surgery (may require staged approach with temporary splinting) and post-operative wound healing, particularly in diabetics/smokers where complication rates are higher; early weight-bearing protocols post-fixation are increasingly favoured where fixation is stable.
- Calcaneal fracture: Conservative management (immobilisation, elevation, delayed weight-bearing) first-line for minimally displaced, extra-articular fractures; surgical fixation (ORIF) for displaced intra-articular fractures to restore joint congruity, ideally once swelling settles; monitor for wound complications (notably high with the lateral extensile approach) and subtalar joint stiffness/arthritis long-term; smokers have markedly higher wound complication rates and should be counselled accordingly.
- Pelvic fracture (unstable): Haemodynamic stabilisation with a pelvic binder is immediate first-line in the trauma bay, followed by definitive fixation (external or internal) once the patient is stable; escalate to angioembolisation or preperitoneal packing for ongoing haemorrhage despite binder and resuscitation; monitor haemodynamic status and associated injuries (urogenital, rectal, neurological) closely, as pelvic fractures are frequently part of high-energy polytrauma.
- Spinal fracture (stable, non-neurological): Bracing and analgesia with early mobilisation as tolerated is first-line; monitor for delayed instability or neurological change with follow-up imaging and clinical review; encourage early mobilisation to prevent deconditioning and VTE, particularly in elderly patients where prolonged bed rest carries significant risk.
- Spinal fracture with neurological deficit: Urgent surgical decompression and stabilisation is first-line, ideally within 24 hours of injury where feasible, as earlier decompression is associated with better neurological recovery; maintain spinal precautions and mean arterial pressure targets (typically >85mmHg) to optimise cord perfusion pending surgery; monitor neurological status closely (ASIA scale) and manage complications of spinal cord injury (autonomic dysreflexia, neurogenic bladder/bowel, VTE prophylaxis) proactively.
- Flail chest: Analgesia (including regional techniques such as epidural or paravertebral blocks) and respiratory support (including non-invasive ventilation or mechanical ventilation if respiratory failure develops) first-line; surgical rib fixation considered for severe flail segments, particularly if ventilator-dependent or undergoing thoracotomy for another indication; monitor respiratory status closely given risk of underlying pulmonary contusion worsening over 24-48 hours; aggressive pulmonary toilet and early mobilisation reduce pneumonia risk.
- Femoral shaft fracture: Intramedullary nailing is first-line definitive fixation in most adults, ideally within 24 hours in the stable patient; damage-control external fixation first in the physiologically unstable polytrauma patient, with delayed conversion to nailing; monitor for fat embolism syndrome (respiratory distress, petechiae, confusion) particularly in the first 24-72 hours, and for blood loss which can be substantial even in closed fractures.
- Pathological fracture (metastatic): Surgical stabilisation (often with adjuvant cement/prosthetic reconstruction) first-line to enable pain relief and mobilisation, followed by radiotherapy to the fixation site; monitor for further skeletal-related events and consider bisphosphonates/denosumab; investigate for the primary tumour if not already known, as management (and prognosis) depends heavily on tumour type; multidisciplinary oncological input guides fixation choice and post-operative systemic therapy.
- Chronic osteomyelitis (with sequestrum): Surgical debridement with sequestrectomy is first-line, as chronic infection with dead bone rarely resolves with antibiotics alone; prolonged targeted antibiotics (often with local antibiotic-eluting beads/spacers) as an adjunct; monitor for recurrence, which is common, and for the resulting bone defect requiring staged reconstruction (bone grafting, distraction osteogenesis); malignant transformation (Marjolin's ulcer) is a rare but recognised long-term complication of chronic sinus tracts.
- Avascular necrosis of the femoral head: Core decompression first-line for early-stage disease (pre-collapse) to relieve intraosseous pressure and potentially preserve the joint; total hip arthroplasty for advanced disease with collapse and secondary osteoarthritis; monitor disease progression with serial imaging (MRI is most sensitive) as early intervention offers the best chance of joint preservation; address underlying risk factors (corticosteroid use, alcohol excess, sickle cell disease) where modifiable.
- Tennis elbow (lateral epicondylitis): Activity modification, physiotherapy (eccentric strengthening), and bracing first-line; corticosteroid injection can give short-term relief but is associated with higher recurrence than physiotherapy alone, so is used judiciously; surgical debridement for refractory disease beyond 6-12 months of conservative therapy; monitor functional improvement, as most cases resolve spontaneously over 1-2 years even without intervention.
- Plantar fasciitis: Stretching, orthotics, and activity modification first-line; corticosteroid injection or extracorporeal shockwave therapy for refractory pain beyond several months; surgical release reserved for cases failing extensive conservative management (typically 6-12 months); monitor for plantar fascia rupture risk with repeated corticosteroid injections; most cases resolve within a year with conservative measures alone.
- De Quervain's tenosynovitis: Splinting and activity modification first-line; corticosteroid injection into the first dorsal compartment for persistent symptoms; surgical release for refractory cases; monitor for recurrence, particularly in new mothers (repetitive lifting/gripping) where symptoms often improve as the causative activity changes.
- Trigger finger: Splinting and activity modification first-line for mild disease; corticosteroid injection into the flexor tendon sheath is highly effective and typically first-line for more established disease; surgical release (percutaneous or open) for cases failing one or two injections; higher recurrence and lower injection response rates are seen in diabetics, who often need earlier surgical referral.
- Dupuytren's contracture: Observation for early disease without functional limitation; collagenase injection or needle fasciotomy for cords causing mild-moderate contracture; surgical fasciectomy for more severe or recurrent contracture affecting hand function; monitor for disease recurrence, which is common regardless of treatment modality, and counsel on the genetic/familial and alcohol-related associations.
- Ganglion cyst: Observation first-line, as many resolve spontaneously; aspiration for symptomatic relief, though recurrence is common; surgical excision for persistent, painful, or functionally limiting cysts, or where diagnosis is uncertain; monitor for recurrence post-excision and reassure patients that ganglions are benign.
- Osgood-Schlatter disease: Activity modification and analgesia first-line, as the condition is self-limiting and typically resolves with skeletal maturity; physiotherapy (quadriceps stretching) as an adjunct; surgical excision of a persistent ossicle rarely needed only if symptoms persist into adulthood; monitor growth and reassure families about the benign, self-limiting course.
- Perthes disease: Containment bracing or activity modification first-line for younger children with mild disease and good femoral head coverage; surgical containment (osteotomy) for older children, more severe disease, or poor femoral head coverage on imaging; monitor femoral head shape and hip range of motion with serial imaging through the disease course (which spans years); prognosis is better with younger age at onset and less femoral head involvement.
- Talipes equinovarus (recurrence): Repeat Ponseti casting and bracing first-line for recurrence after initial correction, as non-compliance with the foot abduction brace is the most common cause; tendon transfer surgery for recurrent relapse despite good brace compliance; monitor brace adherence closely, as recurrence is strongly linked to inconsistent bracing use during the maintenance phase.
- Rickets (nutritional): Vitamin D and calcium supplementation first-line, with correction of dietary/sunlight exposure deficiencies; monitor bone deformity and biochemical markers (calcium, phosphate, alkaline phosphatase, vitamin D level) for response to therapy; surgical correction of residual bony deformity (e.g. bowing) is reserved for cases persisting after biochemical normalisation and skeletal maturity; screen for and address underlying malabsorption or renal causes if response to standard therapy is poor.
- Charcot arthropathy (non-diabetic): Immobilisation and offloading (total contact casting) first-line to prevent progressive joint destruction during the acute phase; surgical reconstruction/fusion for established deformity causing instability or recurrent ulceration; monitor with serial imaging for progression, as the joint remains at risk of further collapse until the acute inflammatory phase resolves; identify and manage the underlying neuropathic cause (e.g. syphilis, syringomyelia, alcohol-related neuropathy).
- Compartment syndrome (chronic exertional): Activity modification and physiotherapy first-line for mild disease; fasciotomy (open or endoscopic) for symptoms significantly limiting activity/sport despite conservative measures; confirm the diagnosis with intracompartmental pressure testing before and after exercise, as this is a clinical/physiological diagnosis distinct from acute compartment syndrome; monitor for recurrence post-fasciotomy, which occurs in a minority.
Obstetrics & Gynaecology
- Obstructed/prolonged labour: Close partographic monitoring with oxytocin augmentation first-line where contractions are inadequate and the pelvis is adequate; emergency caesarean section if obstruction is confirmed (cephalopelvic disproportion, malposition) or fetal distress develops; monitor fetal heart rate continuously and maternal vitals for signs of uterine rupture (especially in a scarred uterus); prolonged obstructed labour risks obstetric fistula, underscoring the importance of timely escalation.
- Umbilical cord prolapse: Immediate manual elevation of the presenting part to relieve cord compression, with the mother positioned in knee-chest or Trendelenburg, followed by emergency caesarean section as definitive management; monitor fetal heart rate continuously during transfer to theatre; if full dilatation and criteria are met, an assisted vaginal delivery may be faster than caesarean; bladder filling can be used as an adjunct to relieve compression during transfer.
- Placental abruption (moderate-severe): Maternal resuscitation (IV fluids, blood products as needed) and continuous fetal monitoring first-line, with expedited delivery (caesarean if fetal distress or significant abruption, vaginal if stable and progressing) depending on severity and gestation; monitor closely for disseminated intravascular coagulation and postpartum haemorrhage, both common complications; anti-D prophylaxis in Rh-negative mothers.
- Uterine fibroids (asymptomatic/incidental): Observation first-line for asymptomatic fibroids not affecting fertility; medical therapy (GnRH agonists, ulipristal) for symptom control or pre-operative shrinkage; myomectomy or hysterectomy for large/symptomatic fibroids depending on fertility wishes; monitor growth in pregnancy (rapid growth/red degeneration can cause pain) and reassess if new symptoms develop.
- Ovarian cyst: Observation with interval ultrasound first-line for simple, small (<5cm), asymptomatic cysts, as most resolve spontaneously; surgical removal (cystectomy, preserving ovarian tissue where possible) for large, symptomatic, complex, or suspicious cysts; monitor tumour markers (CA-125) and imaging features for malignant potential, particularly in postmenopausal women where the threshold for surgical removal is lower.
- Cervical carcinoma: Staging (clinical/imaging) determines treatment: radical hysterectomy with lymphadenectomy first-line for early-stage disease, or definitive chemoradiotherapy for locally advanced disease; fertility-sparing radical trachelectomy an option in very early disease for appropriate candidates; monitor with regular clinical follow-up and cervical cytology/HPV testing post-treatment; HPV vaccination and screening remain the primary prevention strategies.
- Amenorrhea: Systematic evaluation (pregnancy test first, then hormonal panel, pelvic imaging) to identify the underlying cause (hypothalamic-pituitary, ovarian, uterine/outflow tract) before targeted treatment; monitor bone health in hypoestrogenic states (functional hypothalamic amenorrhoea) given fracture risk; address the underlying driver (weight, stress, exercise in hypothalamic causes; hormone replacement in ovarian insufficiency) rather than treating amenorrhoea symptomatically alone.
- Preterm premature rupture of membranes: Antibiotics (typically erythromycin-based regimens) to prolong latency and reduce infection, plus antenatal corticosteroids for fetal lung maturity, first-line; magnesium sulfate for neuroprotection if very preterm; monitor closely for chorioamnionitis (fever, tachycardia, uterine tenderness) and fetal wellbeing, balancing infection risk against prematurity risk when timing delivery.
- Transverse lie: External cephalic version if feasible and no contraindication, attempted from around 36-37 weeks; caesarean section for delivery if version fails, contraindicated, or in labour, as vaginal delivery in transverse lie risks cord prolapse and obstructed labour; monitor for spontaneous version, which can occur up to term.
- Ectopic pregnancy (unruptured, stable): Methotrexate first-line for eligible small unruptured ectopics (low beta-hCG, no fetal cardiac activity, no significant pain) with serial beta-hCG monitoring to confirm resolution; surgical (laparoscopic) management otherwise; monitor for treatment failure or rupture requiring conversion to surgery; anti-D prophylaxis in Rh-negative women.
- Ectopic pregnancy (ruptured): Emergency surgical management (laparoscopic or open salpingectomy/salpingostomy) with concurrent resuscitation is definitive and time-critical given risk of haemorrhagic shock; monitor haemodynamic status closely and cross-match blood; anti-D prophylaxis in Rh-negative women; counsel on future ectopic risk and fertility.
- Miscarriage (incomplete): Expectant, medical (misoprostol), or surgical evacuation first-line depending on patient preference, bleeding severity, and clinical status; monitor for heavy bleeding or infection with expectant/medical management, with a low threshold to proceed to surgical evacuation if either occurs; anti-D prophylaxis in Rh-negative women undergoing surgical management or with significant bleeding.
- Preeclampsia (severe): Blood pressure control (labetalol/nifedipine/hydralazine) and magnesium sulfate seizure prophylaxis first-line, with timed delivery once maternal/fetal condition dictates; escalate antihypertensives if targets not met and monitor for HELLP syndrome/eclampsia; monitor renal function, liver function, and platelet count closely; delivery is the only definitive cure, with timing balancing maternal safety against fetal maturity.
- Eclampsia: Magnesium sulfate to control and prevent further seizures is first-line, alongside blood pressure control and expedited delivery once the mother is stabilised; monitor for magnesium toxicity (reflexes, respiratory rate, urine output) especially in renal impairment; continue magnesium for 24 hours post-delivery/last seizure given ongoing seizure risk in this window.
- Postpartum haemorrhage: Uterotonics (oxytocin first-line, adding ergometrine/carboprost/misoprostol for inadequate response) and uterine massage first-line; escalate to balloon tamponade, compression sutures, or surgical measures (uterine artery ligation, hysterectomy as a last resort) if bleeding continues; monitor for disseminated intravascular coagulation and transfuse early in a balanced ratio if blood loss is significant; identify and address the underlying cause (tone, tissue, trauma, thrombin).
- Placenta praevia: Elective caesarean delivery timed to gestational age and bleeding risk is first-line, typically around 36-37 weeks for stable major praevia; emergency caesarean for significant bleeding; monitor for recurrent antepartum haemorrhage and consider antenatal corticosteroids if preterm delivery becomes likely; avoid vaginal examination once praevia is diagnosed given haemorrhage risk.
- Placental abruption (severe, with fetal compromise): Urgent delivery, typically by emergency caesarean, with maternal resuscitation (fluids, blood products) run in parallel is first-line given the time-critical nature of fetal compromise; monitor for disseminated intravascular coagulation and postpartum haemorrhage aggressively, as abruption is a major cause of both; anti-D prophylaxis in Rh-negative mothers.
- Gestational diabetes mellitus: Dietary and lifestyle modification first-line; escalate to insulin or metformin if glycaemic targets are not met on lifestyle measures alone; monitor fetal growth (macrosomia risk) with serial ultrasound and glycaemic control closely through pregnancy; screen for persistent diabetes with a postpartum oral glucose tolerance test, as gestational diabetes confers substantially increased future type 2 diabetes risk.
- Premature rupture of membranes (preterm): Antibiotics and corticosteroids for fetal lung maturity first-line, with expectant management balanced against infection risk; escalate to delivery if chorioamnionitis, fetal distress, or advancing gestation makes expectant management no longer favourable; monitor maternal temperature, fetal heart rate, and inflammatory markers closely for signs of evolving infection.
- Preterm labour: Tocolysis (nifedipine or atosiban) to allow time for corticosteroid administration first-line, plus magnesium sulfate for fetal neuroprotection if very preterm; monitor for contraindications to tocolysis (chorioamnionitis, significant bleeding, severe pre-eclampsia) where delivery should not be delayed; escalate to delivery if tocolysis fails or is contraindicated.
- Chorioamnionitis: Broad-spectrum IV antibiotics and expedited delivery (regardless of gestation) is first-line, as this is an obstetric emergency with maternal sepsis and fetal risk; monitor maternal temperature, fetal heart rate, and inflammatory markers closely; neonatal team should be alerted for early-onset neonatal sepsis risk given in-utero exposure.
- Polycystic ovary syndrome: Lifestyle modification (weight management) first-line, particularly given metabolic overlap; combined oral contraceptives for cycle regulation and hyperandrogenism in those not seeking pregnancy; metformin and/or ovulation induction (letrozole/clomiphene) for fertility; monitor metabolic parameters (glucose tolerance, lipids) given increased long-term cardiometabolic risk; screen for endometrial hyperplasia risk with prolonged amenorrhoea.
- Endometriosis: NSAIDs and hormonal suppression (combined contraceptives, progestins, or GnRH agonists) first-line for pain control; surgical excision/ablation for refractory pain or fertility concerns, with assisted reproduction considered alongside or instead of repeat surgery; monitor symptom recurrence, which is common after stopping hormonal suppression; counsel on the chronic, relapsing nature of the disease.
- Uterine fibroids (symptomatic): Hormonal therapy (levonorgestrel IUD, GnRH agonists, ulipristal) for symptom control first-line; myomectomy for those wishing to preserve fertility, or hysterectomy for definitive treatment in those who have completed childbearing; monitor haemoglobin given menorrhagia-related anaemia; uterine artery embolisation is an alternative for those wishing to avoid surgery, though less suitable if future fertility is desired.
- Pelvic inflammatory disease: Empirical broad-spectrum antibiotics covering gonorrhoea, chlamydia, and anaerobes first-line, started promptly on clinical suspicion without waiting for swab results; escalate to IV antibiotics and consider surgical drainage for tubo-ovarian abscess or failure to respond to oral therapy within 72 hours; monitor for infertility, ectopic pregnancy risk, and chronic pelvic pain as long-term sequelae; partner treatment and contact tracing are essential.
- Endometrial carcinoma (early stage): Total hysterectomy with bilateral salpingo-oophorectomy (with lymph node assessment) is first-line for early-stage disease; adjuvant radiotherapy for high-risk histological features; fertility-sparing progestin therapy an option in carefully selected young women with early, low-grade disease wishing to preserve fertility; monitor for recurrence with clinical follow-up; postmenopausal bleeding should always prompt urgent endometrial assessment given this diagnosis.
- Preterm pre-eclampsia with severe features: Expedited delivery balanced against fetal maturity is first-line once severe features develop, with corticosteroids given if time allows; maternal stabilisation (blood pressure control, magnesium sulfate) takes priority over prolonging pregnancy; monitor maternal end-organ function (renal, hepatic, haematological) and fetal wellbeing closely, as deterioration can be rapid.
- Molar pregnancy: Suction curettage evacuation is first-line, with tissue sent for histology to confirm diagnosis and exclude choriocarcinoma; serial beta-hCG monitoring post-evacuation until normalisation and beyond, given risk of persistent gestational trophoblastic disease; escalate to chemotherapy if beta-hCG plateaus or rises; effective contraception is advised during the monitoring period to avoid confounding a new pregnancy with persistent disease.
- Vaginal candidiasis: Topical or oral antifungal therapy (azoles) is first-line; escalate to longer courses for recurrent disease (4 or more episodes/year), with maintenance suppressive therapy considered; monitor for underlying predisposing factors (diabetes, immunosuppression, recent antibiotics) in recurrent cases; treatment of asymptomatic colonisation is not routinely recommended.
- Hyperemesis gravidarum: IV fluids and electrolyte correction plus antiemetics (first-line agents such as cyclizine/promethazine, escalating to ondansetron or corticosteroids for refractory cases) first-line; thiamine supplementation before/alongside dextrose-containing fluids to prevent Wernicke's encephalopathy; monitor weight, ketones, and electrolytes; consider enteral or parenteral nutrition in severe, prolonged cases with significant weight loss.
- Recurrent pregnancy loss: Systematic investigation for underlying cause (antiphospholipid syndrome, parental karyotype, uterine anomaly, thrombophilia) with targeted therapy where identified (e.g. aspirin/heparin for antiphospholipid syndrome); monitor closely in subsequent pregnancies with early reassurance scans; a significant proportion remain unexplained despite full work-up, and supportive care/psychological support is an important component of management.
- Cervical incompetence: Cervical cerclage in a subsequent pregnancy (typically placed around 12-14 weeks) is first-line for women with a history of painless second-trimester loss consistent with cervical insufficiency; progesterone supplementation as an adjunct in high-risk pregnancies; monitor cervical length by transvaginal ultrasound serially where cerclage is not placed prophylactically, allowing rescue cerclage if shortening is detected.
- Intrahepatic cholestasis of pregnancy: Ursodeoxycholic acid for symptom relief and to lower bile acid levels is first-line, alongside increased fetal surveillance; consideration of early delivery (around 37-38 weeks, earlier if bile acids very high) given increased stillbirth risk; monitor liver function tests and bile acid levels serially; pruritus typically resolves rapidly post-delivery, confirming the diagnosis retrospectively.
- Amniotic fluid embolism: Immediate resuscitation (airway, oxygen, circulatory support with fluids/vasopressors, correction of coagulopathy with blood products) is first-line in this obstetric emergency; escalate to ICU-level supportive care, including consideration of ECMO in refractory cardiovascular collapse; monitor closely for disseminated intravascular coagulation, which is almost universal; perimortem caesarean section should be considered without delay if maternal cardiac arrest occurs and the fetus is viable.
- Uterine rupture: Emergency laparotomy for delivery and uterine repair (or hysterectomy if repair is not feasible/further childbearing not desired) is first-line and time-critical given risk of catastrophic haemorrhage and fetal death; monitor haemodynamic status closely and resuscitate aggressively in parallel; risk factors (previous caesarean, uterine surgery) should prompt vigilance for scar dehiscence signs in labour.
- Shoulder dystocia: Systematic manoeuvres (McRoberts positioning, suprapubic pressure, escalating to internal rotational manoeuvres or delivery of the posterior arm) to deliver the anterior shoulder is first-line, performed calmly and in sequence; monitor for neonatal brachial plexus injury and clavicular fracture, and for maternal postpartum haemorrhage/perineal trauma; document the time from head delivery to body delivery and manoeuvres used.
- Cord prolapse: Immediate manual elevation of the presenting part and emergency caesarean delivery is first-line, as with earlier cord prolapse entries, given the shared time-critical pathophysiology; monitor fetal heart rate continuously during preparation for delivery; consider immediate vaginal delivery only if full dilatation and low station make it faster than caesarean.
- Twin-to-twin transfusion syndrome: Fetoscopic laser ablation of communicating placental vessels is first-line for severe cases (typically Quintero stage II or above); serial amnioreduction as an alternative or adjunct where laser is unavailable; monitor both twins closely with serial ultrasound (fluid volumes, Doppler, growth) after treatment given ongoing risk of recurrence or single twin demise; refer promptly to a fetal medicine centre once diagnosed given the rapid disease trajectory.
- Multiple pregnancy (uncomplicated twins): Increased-frequency antenatal surveillance (growth scans, chorionicity-based monitoring) is first-line, with monochorionic twins monitored more intensively than dichorionic given shared placental circulation risks; monitor for twin-specific complications (growth discordance, twin-to-twin transfusion in monochorionic pregnancies) and pre-eclampsia, which is more common in multiple pregnancy; plan delivery timing and mode based on chorionicity and presentation.
- Rhesus isoimmunisation: Anti-D prophylaxis at sensitising events and routinely in the third trimester is first-line prevention in Rh-negative women; once isoimmunised, serial monitoring of maternal antibody titres and fetal middle cerebral artery Doppler for anaemia, escalating to intrauterine transfusion for significant fetal anaemia; monitor closely in subsequent pregnancies given risk of earlier and more severe disease; neonatal exchange transfusion may be required for severe haemolytic disease of the newborn.
- Bacterial vaginosis: Oral or vaginal metronidazole (or clindamycin) is first-line; escalate to longer or alternative regimens for recurrent disease; monitor for recurrence, which is common; treat symptomatic pregnant women given an association with preterm birth, though routine screening/treatment of asymptomatic women is not universally recommended; partner treatment is not routinely required.
- Trichomoniasis: Oral metronidazole (single dose or extended course) is first-line for both the patient and their partner(s), given it is a sexually transmitted infection; monitor for treatment failure and re-infection; screen for other sexually transmitted infections given frequent co-infection; treat in pregnancy given association with preterm birth and low birth weight.
- Vulvar carcinoma (early): Wide local excision (with sentinel lymph node biopsy or inguinofemoral lymphadenectomy depending on depth of invasion) is first-line for early-stage disease; radiotherapy/chemoradiotherapy for locally advanced or unresectable disease; monitor for local recurrence with regular follow-up examination; associations with lichen sclerosus and HPV should prompt ongoing surveillance of the vulva.
- Vaginal carcinoma: Radiotherapy or surgery (depending on stage and site) is first-line, with radiotherapy often preferred given anatomical constraints on surgical margins; monitor for local recurrence and treatment-related morbidity (vaginal stenosis); screen for a primary elsewhere (cervix, vulva) as primary vaginal carcinoma is rare and secondary involvement more common.
- Adenomyosis: Hormonal therapy (levonorgestrel IUD, combined contraceptives, or progestins) first-line for symptom control; hysterectomy for definitive treatment in those who have completed childbearing and have refractory symptoms; monitor haemoglobin given associated menorrhagia; MRI can help distinguish from fibroids and guide conservative surgical options where fertility preservation is desired.
- Asherman's syndrome: Hysteroscopic adhesiolysis is first-line, followed by measures to prevent re-adhesion (intrauterine balloon/device, oestrogen therapy); monitor menstrual return and fertility outcomes, with repeat hysteroscopy if symptoms recur; counsel on variable fertility outcomes even after successful adhesiolysis depending on adhesion severity.
- Premature ovarian insufficiency: Hormone replacement therapy is first-line, both for symptom control and to protect long-term bone and cardiovascular health given the prolonged oestrogen-deficient period; fertility options (donor oocyte) discussed for those desiring pregnancy; monitor bone density and cardiovascular risk factors; investigate for underlying cause (autoimmune, genetic, iatrogenic) where relevant.
- Menorrhagia (heavy menstrual bleeding): Levonorgestrel IUD or tranexamic acid/NSAIDs first-line depending on contraceptive needs; escalate to combined contraceptives or endometrial ablation for refractory symptoms in those who have completed childbearing; hysterectomy reserved for failure of less invasive measures; monitor haemoglobin and investigate for structural causes (fibroids, polyps) or coagulopathy, particularly in adolescents.
- Dysmenorrhoea (primary): NSAIDs first-line, given their action against prostaglandin-mediated uterine contraction; combined oral contraceptives as an alternative or adjunct; monitor response and reconsider the diagnosis (screening for endometriosis) if symptoms are refractory to standard first-line therapy, as primary dysmenorrhoea should respond well to NSAIDs/hormonal suppression.
- Female genital prolapse: Pelvic floor physiotherapy and pessary use first-line, particularly for those wishing to avoid or delay surgery; surgical repair (native tissue or mesh-based, per current guidance) for symptomatic prolapse refractory to conservative measures; monitor for pessary-related complications (erosion, discharge) with regular review; recurrence risk after surgical repair should be discussed pre-operatively.
- Ovarian torsion: Emergency surgical detorsion (with ovarian conservation where the ovary appears viable) is first-line and time-critical to preserve ovarian function; oophorectomy reserved for clearly necrotic tissue; monitor post-operative ovarian function with follow-up ultrasound; a high index of suspicion is needed as clinical presentation can mimic other causes of acute abdomen.
- Ovarian hyperstimulation syndrome: Supportive management (fluid balance, analgesia, thromboprophylaxis) first-line for mild-moderate disease; escalate to hospital admission, paracentesis for symptomatic ascites, and closer monitoring for severe disease; monitor haematocrit, renal function, and for thromboembolism given haemoconcentration risk; prevention (using a GnRH antagonist protocol and freeze-all strategy in high-risk patients) is key in assisted reproduction settings.
- Postmenopausal bleeding: Urgent endometrial assessment (transvaginal ultrasound with endometrial biopsy if thickened) is first-line given the need to exclude endometrial carcinoma; hysteroscopy with targeted biopsy if focal pathology (polyp) is suspected; monitor for recurrent bleeding even after benign initial assessment, warranting further investigation; any postmenopausal bleeding should be treated as potential malignancy until proven otherwise.
Paediatrics & Neonatology
- Neonatal jaundice: Phototherapy guided by bilirubin nomograms (age-in-hours specific) first-line for significant hyperbilirubinaemia; exchange transfusion for severe, rapidly rising, or refractory levels approaching neurotoxic thresholds; monitor bilirubin trend closely (more frequently if rising rapidly or risk factors present) and feeding/hydration status; screen for haemolytic causes (ABO/Rh incompatibility, G6PD deficiency) if jaundice is early, severe, or rapidly progressive.
- Cerebral palsy: Multidisciplinary rehabilitation (physiotherapy, occupational therapy, orthotics, speech therapy) tailored to the child's functional profile is first-line; escalate to botulinum toxin injections or oral antispasmodics for troublesome spasticity, with selective dorsal rhizotomy or intrathecal baclofen for severe refractory spasticity; monitor growth, hip surveillance (dislocation risk), and seizure control where epilepsy coexists; early intervention improves functional outcomes.
- Type 1 diabetes mellitus in children: Basal-bolus insulin therapy with structured education for the child and family is first-line; escalate to insulin pump therapy for those with recurrent hypoglycaemia or suboptimal control on injections; monitor HbA1c, growth, and screen annually for microvascular complications and coeliac/thyroid autoimmunity from a defined age; involve the family in carbohydrate counting and sick-day rules to prevent diabetic ketoacidosis.
- Acute glomerulonephritis in children: Supportive management of fluid balance and blood pressure first-line, with treatment of any underlying streptococcal infection (antibiotics if active infection present); monitor renal function, blood pressure, and urine output closely during the acute phase given risk of hypertensive emergency and fluid overload; most cases resolve fully, but persistent proteinuria/hypertension warrants nephrology follow-up.
- Complex febrile seizure: Evaluate for an underlying CNS infection or structural cause (lumbar puncture/imaging as indicated by clinical features) first-line, given atypical features (prolonged, focal, or recurrent within 24 hours) raise concern beyond simple febrile seizures; antipyretics and seizure first-aid advice for the family; monitor for recurrence and consider EEG/further work-up if atypical features persist or recur; most children have a good long-term neurological outcome.
- Congenital anomalies (general): Multidisciplinary assessment and coordinated surgical/medical management depending on the specific anomaly is first-line; monitor growth and development longitudinally, and screen for associated anomalies (cardiac, renal) given clustering in syndromic presentations; genetic counselling for the family regarding recurrence risk where a syndrome or inherited cause is identified.
- Neonatal jaundice (physiological, significant): Phototherapy guided by bilirubin nomograms is first-line; exchange transfusion for severe/refractory hyperbilirubinaemia approaching exchange thresholds; monitor bilirubin trend and adequacy of feeding, as inadequate intake worsens physiological jaundice; reassure that physiological jaundice typically resolves within 1-2 weeks, with prolonged jaundice beyond this warranting further work-up.
- Neonatal sepsis: Empirical broad-spectrum IV antibiotics started promptly on suspicion is first-line, given the rapid deterioration risk in neonates; narrow therapy once culture and sensitivity results are available; monitor closely for haemodynamic instability, respiratory distress, and evolving organ dysfunction; a low threshold for treatment is maintained given the difficulty of clinically excluding sepsis in this age group.
- Respiratory distress syndrome (preterm): Antenatal corticosteroids first-line if preterm birth is anticipated, followed by surfactant therapy and respiratory support (CPAP or ventilation) after delivery; escalate respiratory support as needed while minimising ventilator-induced lung injury; monitor oxygenation, chest X-ray appearance, and for complications (pneumothorax, bronchopulmonary dysplasia) with prolonged ventilation.
- Necrotising enterocolitis: Bowel rest (stopping enteral feeds) and IV antibiotics first-line for suspected/confirmed disease; surgical intervention (laparotomy or peritoneal drain) for perforation or clinical deterioration despite medical therapy; monitor abdominal exam, serial abdominal X-rays, and inflammatory markers closely; breast milk feeding and standardised feeding protocols reduce incidence in preterm infants.
- Hypoxic-ischaemic encephalopathy: Therapeutic hypothermia initiated within 6 hours of birth for eligible moderate-severe cases is first-line, as earlier initiation improves neurodevelopmental outcome; supportive intensive care (seizure control, ventilation, multi-organ support) alongside; monitor with continuous EEG/aEEG for seizures (often subclinical) and serial neurological examination; MRI at day 5-14 helps predict long-term prognosis.
- Patent ductus arteriosus (symptomatic, preterm): Pharmacological closure (indomethacin/ibuprofen/paracetamol) first-line for haemodynamically significant PDA; surgical or catheter-based ligation if medical therapy fails or is contraindicated; monitor for complications of medical therapy (renal impairment, gastrointestinal bleeding) and cardiorespiratory status; many small PDAs close spontaneously, so treatment is reserved for those causing significant compromise.
- Congenital diaphragmatic hernia: Stabilisation and gentle ventilation (avoiding high pressures that worsen pulmonary hypoplasia) first-line, with surgical repair once the infant is haemodynamically stable, typically after 24-72 hours rather than as an emergency; monitor for persistent pulmonary hypertension, a major determinant of outcome; ECMO may be needed as a bridge in severe cases with inadequate gas exchange.
- Pyloric stenosis: IV fluid and electrolyte correction (correcting the characteristic hypochloraemic hypokalaemic metabolic alkalosis) first-line before surgery, as anaesthetic risk is high if uncorrected; pyloromyotomy (open or laparoscopic) is definitive once electrolytes are normalised; monitor feeding tolerance and weight gain post-operatively; surgery is not an emergency and should wait for adequate resuscitation.
- Intussusception: Air or contrast enema reduction is first-line, successful in most cases if performed early; surgery if reduction fails, there are signs of perforation/peritonitis, or a pathological lead point (e.g. Meckel's diverticulum) is suspected, particularly in older children; monitor for recurrence post-reduction (occurs in a minority) and for signs of bowel ischaemia/perforation during the procedure.
- Croup: Oral dexamethasone is first-line for all severities, as it reduces symptom duration and hospitalisation; nebulised adrenaline for severe stridor at rest, with close monitoring afterward for rebound symptoms as the effect is short-lived; monitor respiratory status and consider admission for persistent severe symptoms or stridor at rest despite treatment.
- Bronchiolitis (severe): Supportive oxygen and hydration (nasogastric or IV fluids if oral intake inadequate) first-line, as this is a self-limiting viral illness without specific antiviral treatment; escalate to high-flow nasal cannula or CPAP for increasing work of breathing/hypoxia, with ICU/ventilation for impending respiratory failure; monitor feeding, respiratory rate, and oxygen saturation closely, particularly in infants under 3 months or with comorbidities; avoid routine bronchodilators, steroids, or antibiotics, which lack proven benefit.
- Acute otitis media (paediatric): Analgesia first-line, as many cases resolve spontaneously; antibiotics for young infants (under 6 months), bilateral disease in younger children, otorrhoea, or severe/persistent symptoms beyond 48-72 hours; monitor for treatment failure and complications (mastoiditis) which, though rare, require prompt escalation; recurrent otitis media may warrant ENT referral for grommet insertion.
- Kawasaki disease: IVIG plus high-dose aspirin, started promptly (ideally within 10 days of fever onset) to reduce coronary aneurysm risk, is first-line; escalate to a second dose of IVIG or corticosteroids for IVIG-resistant disease; monitor with serial echocardiography for coronary artery involvement, extending surveillance long-term if aneurysms develop; low-dose aspirin is continued until platelet count and echocardiogram normalise.
- Henoch-Schönlein purpura: Supportive care with analgesia is first-line, as the condition is usually self-limiting; corticosteroids for significant abdominal pain or renal involvement; monitor urinalysis and blood pressure for weeks to months after presentation given risk of delayed nephritis; most children recover fully, but a minority progress to chronic kidney disease requiring nephrology follow-up.
- Nephrotic syndrome (childhood, steroid-sensitive): Oral corticosteroids are first-line for both induction and relapse therapy, with the majority of children responding well; escalate to steroid-sparing agents (calcineurin inhibitors, mycophenolate) for frequent relapsers or steroid dependence; monitor urine protein (dipstick), weight, and blood pressure at home to detect relapse early; screen for steroid side effects with prolonged/frequent courses.
- Febrile seizure (simple): Reassurance and antipyretics is first-line, as antipyretics do not prevent recurrence but improve comfort; no long-term antiepileptic therapy is required given the excellent prognosis; monitor for recurrence (common but not harmful) and educate families on seizure first-aid; investigate further only if atypical features (focal, prolonged, recurrent within the same illness) are present.
- Attention-deficit/hyperactivity disorder: Behavioural therapy and parent training first-line for young children (under 6); stimulant medication (methylphenidate/amphetamines) for older children with significant functional impairment, alongside behavioural strategies; monitor growth, appetite, sleep, and cardiovascular parameters on stimulant therapy; non-stimulant options (atomoxetine, guanfacine) considered where stimulants are contraindicated or poorly tolerated.
- Autism spectrum disorder: Early behavioural and developmental intervention (applied behaviour analysis, speech/occupational therapy) is first-line, with earlier intervention associated with better outcomes; treat comorbid symptoms (irritability, sleep disturbance, anxiety) pharmacologically where significantly impairing; monitor developmental progress and family support needs; screen for co-occurring conditions (epilepsy, intellectual disability, GI symptoms) which are common.
- Failure to thrive: Identify and treat the underlying cause (organic or non-organic) first-line, with nutritional rehabilitation and growth monitoring as the cornerstone; escalate to enteral feeding support for severe or refractory cases where oral intake alone is insufficient; monitor growth parameters (weight, length, head circumference) serially against standardised charts; involve a multidisciplinary team (dietitian, social work) where psychosocial factors contribute.
- Acute rheumatic fever: Anti-inflammatory therapy (aspirin for arthritis, corticosteroids for significant carditis) first-line, alongside eradication of the streptococcal infection with penicillin; secondary penicillin prophylaxis (monthly IM benzathine penicillin) is essential and continued for years depending on carditis severity; monitor for evolving valvular disease with echocardiography; recurrence prevention through prophylaxis adherence is the key long-term determinant of outcome.
- Congenital hypothyroidism: Immediate levothyroxine replacement, started as soon as possible after diagnosis (ideally identified through newborn screening), is first-line to prevent neurodevelopmental impairment; monitor thyroid function closely in the first years of life with dose adjustments as the child grows; delayed treatment beyond the first weeks of life is associated with irreversible cognitive impairment, underscoring the urgency of prompt initiation.
- Cystic fibrosis (paediatric, new diagnosis): Multidisciplinary care including airway clearance physiotherapy, CFTR modulator therapy (if genotype-eligible), pancreatic enzyme replacement, and nutritional support is first-line from diagnosis; monitor growth, lung function, and sputum microbiology regularly; screen for CF-related diabetes and liver disease as the child grows; early comprehensive care significantly improves long-term prognosis.
- Transient tachypnoea of the newborn: Supportive oxygen therapy is first-line, as the condition is usually self-limiting within 24-72 hours due to delayed clearance of fetal lung fluid; monitor respiratory rate and oxygen requirement, distinguishing from more serious causes of neonatal respiratory distress if symptoms persist beyond the expected timeframe or worsen.
- Meconium aspiration syndrome: Respiratory support (oxygen, CPAP, or ventilation as needed) and monitoring for persistent pulmonary hypertension of the newborn is first-line; escalate to surfactant therapy or inhaled nitric oxide for severe hypoxaemia; monitor oxygenation and consider ECMO for refractory cases; suctioning practices at delivery have evolved and should follow current resuscitation guidelines rather than routine deep suctioning.
- Persistent pulmonary hypertension of the newborn: Oxygen and inhaled nitric oxide is first-line to reduce pulmonary vascular resistance; ECMO for refractory cases failing to respond to nitric oxide and optimal ventilation; monitor oxygenation index and echocardiographic estimates of pulmonary pressures closely; treat the underlying cause (meconium aspiration, sepsis, congenital diaphragmatic hernia) concurrently.
- Neonatal hypoglycaemia: IV dextrose is first-line for symptomatic or severe cases; early feeding for at-risk asymptomatic infants (infants of diabetic mothers, preterm, growth-restricted) as an initial measure before escalating to IV dextrose; monitor blood glucose serially according to risk-based protocols; investigate for persistent/recurrent hypoglycaemia (hyperinsulinism, metabolic disorders) if it does not resolve with standard measures.
- Neonatal seizures: Identify and treat the underlying cause (hypoxic-ischaemic encephalopathy, metabolic disturbance, infection, structural abnormality) is first-line, alongside antiepileptic therapy (phenobarbitone first-line) for seizure control; monitor with continuous EEG/aEEG given the high rate of subclinical/electrographic-only seizures in neonates; correct treatable metabolic causes (hypoglycaemia, hypocalcaemia) promptly as these can mimic or cause seizures.
- Congenital hip dislocation (late presenting): Closed or open reduction with spica casting is first-line, with the approach depending on age at diagnosis (closed reduction more successful in younger children, open reduction increasingly needed with delayed presentation); monitor acetabular development and femoral head position with serial imaging post-reduction; avascular necrosis is a recognised complication requiring careful surveillance.
- Biliary atresia: Early Kasai portoenterostomy (ideally before 8 weeks of age) is first-line, as earlier surgery is associated with better bile drainage and native liver survival; liver transplant if Kasai fails or disease progresses to end-stage liver disease; monitor liver function, growth, and for cholangitis (a common post-Kasai complication) closely; early diagnosis (via conjugated bilirubin screening) is critical given the narrow surgical window.
- Gastroschisis: Surgical closure (primary if feasible) is first-line; staged silo reduction for cases where primary closure would cause excessive abdominal pressure/compartment syndrome; monitor bowel function and nutrition closely, as prolonged ileus is common; unlike omphalocele, associated anomalies are less frequent, but bowel-related complications (atresia, dysmotility) require ongoing surveillance.
- Omphalocele: Staged surgical closure is first-line, particularly for large defects where primary closure would compromise ventilation/circulation; assessment for associated anomalies (cardiac, chromosomal, Beckwith-Wiedemann syndrome) is essential given frequent co-occurrence; monitor for these associated conditions proactively, as they often determine overall prognosis more than the abdominal wall defect itself.
- Tracheo-oesophageal fistula: Surgical repair, typically in the neonatal period, is first-line, with staged repair for long-gap variants; monitor for anastomotic leak, stricture, and recurrent fistula post-operatively; screen for associated anomalies (VACTERL association) given frequent clustering; long-term follow-up for oesophageal dysmotility and reflux is often needed.
- Anorectal malformation: Staged surgical reconstruction depending on the type and level of the malformation is first-line, often beginning with a colostomy in high/intermediate lesions followed by definitive pull-through surgery; monitor bowel and urinary function long-term, as continence outcomes vary with malformation complexity; screen for associated anomalies (spinal, renal, cardiac) given frequent co-occurrence.
- Hirschsprung's disease: Surgical pull-through procedure (removing the aganglionic segment) is first-line definitive treatment, often preceded by decompression (rectal irrigation or colostomy) in the neonatal period if the child presents unwell; monitor for post-operative enterocolitis, a significant cause of morbidity, and for long-term bowel function/continence; a rectal biopsy confirming absent ganglion cells is required for diagnosis before surgery.
- Congenital heart disease (duct-dependent): Prostaglandin E1 infusion to maintain ductal patency is first-line immediately on diagnosis/suspicion, as ductal closure can cause rapid haemodynamic collapse; definitive surgical or catheter-based repair once stabilised; monitor oxygen saturation, perfusion, and for apnoea (a recognised prostaglandin side effect); antenatal diagnosis allows planned delivery at a cardiac centre, improving outcomes.
- Down syndrome with duodenal atresia: Surgical duodenoduodenostomy is first-line definitive treatment, usually performed once the infant is stabilised (nasogastric decompression, IV fluids pre-operatively); monitor for associated cardiac defects, which are common in Down syndrome and should be assessed with echocardiography before surgery where feasible; long-term follow-up addresses the broader Down syndrome care plan (thyroid, hearing, developmental surveillance).
- Sudden infant death syndrome (risk reduction): Safe sleep counselling (supine sleeping position, firm sleep surface, room-sharing without bed-sharing, avoiding overheating and soft bedding) is first-line prevention, delivered proactively to all families; monitor and reinforce these messages at each well-child visit; smoking cessation counselling for parents further reduces risk, as maternal smoking is a major modifiable risk factor.
- Breath-holding spells: Reassurance and parental education is first-line, as the condition is benign and self-limiting, typically resolving by school age; screen for and treat iron deficiency anaemia, which is associated with breath-holding spells and treatment of which can reduce frequency; monitor for atypical features (true seizure activity, cardiac cause) if episodes are prolonged or associated with abnormal movements.
- Enuresis (nocturnal, primary): Reassurance, motivational therapy, and bedwetting alarms are first-line, particularly in younger children where spontaneous resolution is common; desmopressin as pharmacological adjunct for short-term control (e.g. for sleepovers) or when alarm therapy fails; monitor for underlying constipation (a common contributor) and treat concurrently; investigate further if daytime symptoms or secondary enuresis (after a dry period) are present.
- Constipation (functional, paediatric): Dietary modification (fibre, fluid) and osmotic laxatives (e.g. macrogol) first-line, often requiring a disimpaction regimen before maintenance therapy; monitor for withholding behaviours and soiling (overflow incontinence), which respond to adequate laxative dosing and behavioural support; maintenance therapy is often needed for months and should not be stopped too early, as premature discontinuation risks relapse.
- Coeliac disease (paediatric): Strict lifelong gluten-free diet is first-line and definitive treatment once diagnosis is confirmed (serology plus duodenal biopsy per current criteria); monitor growth, symptom resolution, and coeliac serology to confirm dietary adherence; screen at-risk groups (type 1 diabetes, Down syndrome, first-degree relatives) periodically given increased prevalence; involve a dietitian for long-term dietary support.
- Type 1 diabetes (new diagnosis, paediatric): Insulin therapy (basal-bolus regimen) started promptly on diagnosis is first-line, with urgent assessment for diabetic ketoacidosis requiring IV fluid and insulin protocols if present; structured diabetes education for the family is essential from diagnosis; monitor blood glucose, growth, and psychosocial adjustment closely in the early period as the family adapts to a chronic condition.
- Precocious puberty (central): GnRH agonist therapy is first-line to halt pubertal progression and preserve adult height potential; monitor growth velocity, bone age, and pubertal staging on treatment; investigate for an underlying CNS cause (particularly in younger children or boys, where the yield of finding a structural lesion is higher) with MRI; treatment is typically continued until an age-appropriate time for normal puberty to resume.
- Growth hormone deficiency: Recombinant growth hormone replacement is first-line once diagnosis is confirmed (auxology plus stimulation testing); monitor growth velocity, bone age, and IGF-1 levels on treatment to guide dosing; investigate for other pituitary hormone deficiencies (panhypopituitarism) and structural causes (pituitary/hypothalamic lesion) with MRI; treatment is most effective when started early and continued through growth completion.
- Juvenile dermatomyositis: Corticosteroids plus a steroid-sparing agent (methotrexate) is first-line; escalate to IVIG or biologic therapy for refractory disease or significant skin/muscle involvement; monitor muscle strength, skin findings, and for calcinosis (a long-term complication); screen for and manage the risk of interstitial lung disease and, rarely, malignancy association in specific antibody subtypes.
- Immune thrombocytopenia (childhood): Observation alone is first-line for mild disease without significant bleeding, as most childhood ITP resolves spontaneously; corticosteroids or IVIG for significant bleeding or very low platelet counts; monitor platelet count and bleeding symptoms; escalate to second-line therapy (rituximab, splenectomy) only for chronic, refractory disease with clinically significant bleeding, which is uncommon in children.
- Acute lymphadenitis (cervical, bacterial): Oral or IV antibiotics (depending on severity) covering typical skin/oral flora (Staphylococcus, Streptococcus) is first-line; drainage for abscess formation not responding to antibiotics alone; monitor clinical response over 48-72 hours, escalating imaging (ultrasound) and treatment if fluctuance develops or symptoms fail to improve; consider atypical causes (mycobacterial, cat-scratch disease) if the presentation is subacute or antibiotic-refractory.
- Umbilical hernia (paediatric): Observation is first-line, as the large majority resolve spontaneously by 2-4 years of age; surgical repair reserved for hernias persisting beyond this age, those that are large, or complicated by incarceration (rare); monitor for signs of incarceration (irreducibility, pain, skin changes) which would prompt urgent surgical referral; reassure families about the generally benign, self-resolving course.
Psychiatry
- Generalized anxiety disorder: Cognitive behavioural therapy and/or SSRIs/SNRIs are first-line; escalate to a second agent or combined CBT plus pharmacotherapy for inadequate response; monitor for suicidality in the early weeks of antidepressant treatment, particularly in younger patients; taper pharmacotherapy slowly after sustained remission (typically 12 months or more) given relapse risk with abrupt discontinuation.
- Post-traumatic stress disorder: Trauma-focused psychotherapy (e.g. CBT or EMDR) is first-line, with SSRIs for pharmacological support particularly where psychotherapy access is limited or comorbid depression is present; monitor for comorbid substance use and suicidality, both common; avoid benzodiazepines as routine treatment given limited efficacy and dependence risk; screen for and address safety in ongoing abusive situations before/alongside trauma-focused work.
- Bipolar depression: A mood stabiliser or an agent with proven bipolar-depression efficacy (e.g. quetiapine, lamotrigine, lurasidone) is first-line; avoid antidepressant monotherapy given the risk of precipitating mania/mixed states or rapid cycling; monitor mood state closely for emergence of hypomanic/manic symptoms; screen for suicidality, which is elevated in bipolar depression; ensure an adequate mood stabiliser is in place before or alongside any antidepressant use.
- Acute agitation/violent behaviour: De-escalation techniques are first-line; rapid tranquilisation with medication (oral or IM benzodiazepine/antipsychotic) only if safety is at risk and de-escalation fails; monitor sedation level, respiratory status, and vital signs closely after rapid tranquilisation given risk of over-sedation; identify and treat any underlying organic cause (delirium, intoxication, withdrawal) rather than assuming a primary psychiatric cause.
- Suicidal patient (acute risk): Immediate safety assessment, removal of means, and admission or close supervision if risk is high is first-line; escalate to involuntary admission per local legal frameworks if the patient lacks capacity or refuses voluntary care and risk is imminent; monitor risk dynamically, as it can fluctuate rapidly; involve family/support systems where appropriate and ensure follow-up is arranged before any discharge, given the elevated risk period immediately post-discharge.
- Generalised anxiety disorder (chronic, treatment-resistant): Combination CBT plus pharmacotherapy (SSRI/SNRI) is first-line for those failing monotherapy; escalate to augmentation strategies (buspirone, pregabalin) or a different antidepressant class for refractory cases; monitor functional impairment and comorbid depression, which frequently co-occurs; reassess the diagnosis if response remains poor, considering underlying medical causes of anxiety (thyroid disease, cardiac arrhythmia).
- Obsessive-compulsive disorder: Cognitive behavioural therapy (exposure and response prevention) is first-line, with SSRIs at higher doses than typically used for depression as pharmacological first-line/adjunct; escalate to clomipramine or augmentation with an antipsychotic for refractory disease; monitor symptom severity with standardised scales and treatment adherence, as exposure-based therapy requires active patient engagement; longer treatment trials (12+ weeks) are often needed before concluding an agent has failed.
- Social anxiety disorder: Cognitive behavioural therapy and/or SSRIs are first-line; monitor for comorbid substance use (particularly alcohol used for self-medication) and depression; escalate to an SNRI or augmentation strategy for inadequate response to an adequate SSRI trial; screen for avoidant personality traits which may need longer-term psychotherapeutic work beyond symptom-focused CBT.
- Post-traumatic stress disorder (chronic): Trauma-focused psychotherapy is first-line, with pharmacotherapy (SSRIs) as adjunct, particularly for chronic or treatment-resistant presentations; monitor for treatment-resistant symptoms and comorbid conditions (depression, substance use, chronic pain) that commonly accompany chronic PTSD; escalate to specialist trauma services for complex or treatment-refractory presentations, particularly with a history of prolonged or repeated trauma.
- Alcohol withdrawal syndrome: Benzodiazepine-based symptom-triggered therapy (using a validated withdrawal scale) is first-line, with thiamine given before/alongside glucose to prevent Wernicke's encephalopathy; escalate to fixed-dose or higher-dose benzodiazepine regimens for severe withdrawal or seizure history; monitor vital signs and withdrawal scores frequently in the acute phase; screen for and correct electrolyte abnormalities (magnesium, potassium) which can complicate withdrawal.
- Delirium tremens: IV benzodiazepines (often high-dose, symptom-triggered) is first-line, with supportive care (fluid, electrolyte correction) and thiamine replacement given concurrently; escalate to ICU-level care and consider adjunctive agents (phenobarbitone, propofol) for refractory cases requiring intubation; monitor for autonomic instability, seizures, and hyperthermia closely given the significant mortality risk of untreated delirium tremens.
- Anorexia nervosa: Nutritional rehabilitation and psychotherapy (family-based therapy in adolescents, CBT in adults) is first-line; escalate to inpatient/day-programme care for medical instability (bradycardia, electrolyte disturbance, rapid weight loss) or failure of outpatient treatment; monitor for refeeding syndrome closely when reintroducing nutrition after prolonged starvation, with gradual caloric increase and electrolyte/phosphate monitoring; involve a multidisciplinary team (medical, dietetic, psychiatric) throughout.
- Bulimia nervosa: Cognitive behavioural therapy is first-line; SSRIs (particularly fluoxetine, at higher doses than for depression) as adjunct or for those declining/not responding to psychotherapy alone; monitor electrolytes (particularly potassium) given purging-related risk of hypokalaemia and cardiac arrhythmia; screen for dental erosion and oesophageal complications from recurrent vomiting, and address comorbid mood/anxiety disorders which are common.
- Insomnia disorder: Cognitive behavioural therapy for insomnia is first-line, with superior long-term efficacy to pharmacotherapy; short-term pharmacotherapy (Z-drugs, or low-dose sedating antidepressants) as adjunct for acute exacerbations, avoiding long-term use given dependence and tolerance risk; monitor sleep patterns (sleep diary) and screen for underlying contributors (sleep apnoea, mood disorder, substance use) rather than treating insomnia in isolation.
- Adjustment disorder: Supportive psychotherapy, generally time-limited, is first-line, focused on adaptive coping with the identified stressor; monitor for evolution into a more persistent mood or anxiety disorder if symptoms do not resolve within the expected timeframe (typically within 6 months of stressor resolution); pharmacotherapy is not routinely first-line but may be considered if symptoms are severe or the diagnosis evolves.
- Delirium (acute confusional state): Identify and treat the underlying cause (infection, metabolic disturbance, medication, withdrawal) is first-line, alongside reorientation strategies and minimal use of sedatives; escalate to low-dose antipsychotic only if severe agitation poses safety risk and non-pharmacological measures fail; monitor cognitive status serially (e.g. CAM) and avoid benzodiazepines except in withdrawal-related delirium, as they can worsen confusion in other causes.
- Catatonia: A benzodiazepine trial (typically lorazepam) is first-line, often producing rapid dramatic improvement that is also diagnostically confirmatory; electroconvulsive therapy for refractory cases or when rapid resolution is needed (e.g. malignant catatonia with autonomic instability); monitor for malignant catatonia features (fever, autonomic instability, rigidity) which constitute a medical emergency; identify and treat the underlying psychiatric or medical cause once stabilised.
- Conduct disorder: Multimodal behavioural and family-based intervention (parent management training, multisystemic therapy) is first-line; pharmacotherapy targeted at specific comorbid symptoms (e.g. stimulants for comorbid ADHD, or mood stabilisers for severe aggression) as adjunct rather than primary treatment; monitor for evolution into antisocial personality patterns and screen for comorbid substance use, learning difficulties, and trauma history which often underlie presentations.
- Substance use disorder (opioid): Opioid agonist therapy (methadone or buprenorphine) combined with psychosocial support is first-line, with strong evidence for reducing overdose mortality and illicit use; monitor for treatment retention and concurrent use of other substances (benzodiazepines, alcohol) which increase overdose risk when combined with opioid agonist therapy; provide naloxone and overdose education to patients and their contacts regardless of treatment engagement.
- Gambling disorder: Cognitive behavioural therapy and support-group involvement (e.g. Gamblers Anonymous) is first-line; monitor for comorbid substance use and mood disorders, which frequently co-occur; screen for financial and relationship harms, and consider referral to financial counselling/legal support alongside psychological treatment given the practical consequences that often drive presentation.
- Schizoaffective disorder: Combination antipsychotic and mood-stabilising/antidepressant therapy, tailored to the predominant mood component (manic or depressive), is first-line; monitor for metabolic side effects of antipsychotics (weight, glucose, lipids) with regular screening; escalate to clozapine for treatment-resistant psychotic symptoms; long-term maintenance therapy is usually required given the chronic, relapsing course.
- Delusional disorder: Antipsychotic therapy is first-line, though engagement can be challenging given limited insight typical of this condition; build a therapeutic alliance gradually rather than confronting the delusion directly, which often worsens engagement; monitor functional impact, as many patients maintain relatively preserved functioning outside the delusional system; assess for risk to self or others related to the specific delusional content (e.g. persecutory beliefs).
- Body dysmorphic disorder: Cognitive behavioural therapy and/or SSRIs at higher doses (similar to OCD dosing) is first-line; monitor for suicidality, which is notably elevated in this condition; screen for and discourage cosmetic/surgical procedures sought to address the perceived defect, as these rarely improve symptoms and may worsen distress; address comorbid depression and social withdrawal which commonly accompany the disorder.
- Hoarding disorder: Specialised cognitive behavioural therapy targeting hoarding-specific behaviours (acquiring, discarding, organising) is first-line, distinct from standard OCD-focused CBT; monitor safety and functional impact of the home environment (fire risk, sanitation, fall hazards), particularly in elderly patients; involve family/community services where safety risks are significant; insight is often limited, requiring a patient, non-confrontational approach.
- Trichotillomania: Habit reversal training is first-line behavioural therapy; monitor for comorbid anxiety and for medical complications (trichobezoar if hair-pulling is accompanied by hair-eating); pharmacotherapy has limited evidence but N-acetylcysteine or SSRIs are sometimes trialled for refractory cases; address underlying stress/anxiety triggers alongside the behavioural intervention.
- Dissociative identity disorder: Long-term trauma-focused psychotherapy is first-line, working toward integration or cooperative functioning between identity states; monitor for self-harm and suicidality, which are common given the typically severe trauma history; ensure safety and stabilisation are established before deeper trauma processing work, as premature exploration can be destabilising; screen for comorbid PTSD and complex trauma presentations.
- Depersonalisation-derealisation disorder: Psychotherapy addressing underlying anxiety/trauma is first-line; SSRIs as adjunct, though evidence is modest; monitor for comorbid anxiety and depression, which are common drivers/co-occurring conditions; reassure patients that the experience, while distressing, is not indicative of psychosis, as this reassurance itself can reduce secondary anxiety about the symptoms.
- Conversion disorder (functional neurological symptom disorder): Multidisciplinary rehabilitation with physiotherapy and psychological therapy is first-line, alongside clear, non-judgemental communication of the diagnosis as a genuine condition rather than "faking"; monitor functional recovery with a rehabilitative rather than purely psychiatric framing; avoid unnecessary repeated investigations once organic causes have been reasonably excluded, as this can reinforce illness anxiety and delay rehabilitation engagement.
- Factitious disorder: Non-confrontational psychiatric engagement, focusing on underlying psychological needs rather than direct confrontation about symptom fabrication, is first-line; monitor for harm from unnecessary medical procedures/investigations sought by the patient; involve a consistent care team and avoid excessive investigation to reduce iatrogenic harm; distinguish carefully from malingering, where external incentive (rather than psychological need) drives symptom fabrication.
- Postpartum depression: Psychotherapy and/or antidepressants (selecting agents compatible with breastfeeding where relevant) is first-line, with attention to mother-infant bonding and safety; monitor for suicidal ideation and, importantly, any thoughts of harm toward the infant, which require urgent escalation; involve partners/family in support and screen using validated tools (e.g. Edinburgh Postnatal Depression Scale) at routine postnatal contacts.
- Postpartum psychosis: Urgent psychiatric admission (mother-baby unit where available) is first-line given the high acuity and risk to both mother and infant; antipsychotic and/or mood-stabilising therapy alongside close monitoring; monitor closely for rapid symptom evolution and risk of harm to self or infant, as this is a psychiatric emergency; involve family and child protection services as appropriate to ensure infant safety during the acute episode.
- Seasonal affective disorder: Light therapy is first-line, typically administered in the morning; antidepressants for more severe presentations or inadequate response to light therapy alone; monitor mood seasonally and consider prophylactic treatment initiation before the anticipated seasonal onset in patients with a clear recurrent pattern; screen for bipolar spectrum features, as seasonal mood episodes can occur in bipolar disorder.
- Premenstrual dysphoric disorder: SSRIs (continuous or luteal-phase-only dosing) are first-line pharmacotherapy, with luteal-phase dosing offering similar efficacy with less cumulative exposure; combined oral contraceptives as an alternative/adjunct; monitor symptom timing with a prospective symptom diary across at least two cycles to confirm the diagnosis before committing to long-term treatment, as retrospective recall is unreliable.
- Nicotine dependence: Behavioural support combined with nicotine replacement therapy or varenicline/bupropion is first-line; monitor quit attempts and relapse, providing repeated brief interventions as relapse is common and does not preclude eventual success; screen for and address comorbid mental health conditions, which are more prevalent among smokers and can complicate quit attempts if untreated.
- Cannabis use disorder: Psychosocial interventions (motivational interviewing, CBT) are the mainstay, as no approved pharmacotherapy exists; monitor for cannabis-induced psychosis or exacerbation of underlying psychotic/mood disorders, particularly with high-potency products; screen for and address comorbid conditions, and provide education on risks of early-onset heavy use, particularly regarding psychosis risk in vulnerable individuals.
- Stimulant use disorder: Psychosocial treatment (CBT, contingency management) is the mainstay, as no approved pharmacotherapy exists; manage acute complications (cardiovascular events, psychosis) symptomatically as they arise; monitor for stimulant-induced psychosis, which usually resolves with abstinence but may require short-term antipsychotic treatment; screen for cardiovascular risk given stimulant-related cardiac strain.
- Sedative-hypnotic withdrawal: Gradual tapering of the sedative agent (using an equivalent long-acting benzodiazepine if needed) is first-line to avoid withdrawal seizures, which can occur with abrupt cessation particularly of high-dose or long-term use; monitor for withdrawal symptoms and seizure risk closely during the taper; inpatient management is warranted for high-dose dependence or history of severe withdrawal/seizures.
- Intellectual disability (management of comorbidities): Individualised educational and behavioural support is first-line, with treatment of comorbid psychiatric/medical conditions (anxiety, depression, epilepsy) tailored to the individual's communication and cognitive level; monitor for underrecognised pain or distress presenting as behavioural change, as communication limitations can mask the underlying cause; involve family/carers closely in assessment and care planning given their detailed knowledge of the individual's baseline.
- Tourette syndrome: Behavioural therapy (habit reversal training/comprehensive behavioural intervention for tics) is first-line; alpha-agonists (clonidine/guanfacine) or antipsychotics for significant tic burden not responding to behavioural therapy; monitor tic severity and functional/social impact rather than treating mild tics that do not significantly impair the child; screen for and address common comorbidities (ADHD, OCD) which often drive more functional impairment than the tics themselves.
- Selective mutism: Behavioural therapy with gradual exposure is first-line, involving close collaboration with family and school to create a consistent, low-pressure approach to speaking situations; monitor progress across settings (home, school, community) as generalisation can be slow; screen for underlying social anxiety, which frequently coexists, and consider SSRIs as adjunct for more severe or refractory cases alongside behavioural intervention.
Anaesthesia & Perioperative
- Failed airway: Follow a structured failed-airway algorithm first-line, escalating stepwise from optimised laryngoscopy to a supraglottic device, then to front-of-neck access (surgical/cannula cricothyroidotomy) if oxygenation cannot be achieved; monitor oxygen saturation continuously throughout and declare "can't intubate, can't oxygenate" early rather than persisting with repeated intubation attempts; debrief and document fully afterward, and communicate the difficult airway to the patient and future anaesthetists.
- Contrast reaction (general): Stop the infusion immediately and assess severity is first-line; treat mild reactions symptomatically with antihistamines, escalate to corticosteroids for moderate reactions, and give IM adrenaline promptly for anaphylaxis; monitor airway, breathing, and circulation closely for at least several hours after a significant reaction given risk of biphasic recurrence; document the reaction clearly and consider pre-medication or an alternative contrast agent for future imaging.
- Aspiration during anaesthesia: Suction the airway and position head-down/lateral immediately is first-line, with respiratory support (oxygen, ventilation) as needed; escalate to bronchoscopy for particulate aspiration causing airway obstruction; antibiotics only if pneumonia develops rather than as routine prophylaxis; monitor oxygenation and chest X-ray for 24-48 hours given delayed chemical pneumonitis can evolve after the initial event.
- Postoperative ileus: Bowel rest, nasogastric decompression if significantly distended, early mobilisation, and correction of electrolyte disturbance (particularly potassium) are first-line; escalate to imaging (to exclude mechanical obstruction) if ileus is prolonged beyond the expected 3-5 days; monitor bowel sounds, distension, and tolerance of oral intake, reintroducing feeding gradually as function returns; minimise opioid use where possible given its contribution to ileus.
- Cancer-related chronic pain: WHO analgesic ladder approach first-line, starting with non-opioids and escalating stepwise through weak then strong opioids with adjuvant agents (neuropathic agents, corticosteroids for bone/nerve pain) as needed for adequate control; monitor pain scores regularly and titrate proactively rather than reactively; screen for opioid side effects (constipation, sedation) and co-prescribe a laxative routinely; reassess for disease progression if pain escalates unexpectedly.
- Postoperative nausea and vomiting: Prophylactic antiemetics (e.g. ondansetron, dexamethasone, combined for high-risk patients) for at-risk patients (identified by validated risk scores) is first-line; rescue antiemetic therapy from a different class if prophylaxis fails or was not given; monitor hydration and electrolyte status with persistent vomiting; minimise opioid and volatile anaesthetic use in high-risk patients where feasible as part of a multimodal prevention strategy.
- Difficult airway (anticipated): Awake fibreoptic intubation or a planned structured approach with backup airway equipment immediately available is first-line once a difficult airway is anticipated on assessment; escalate to a surgical airway plan discussed in advance if predicted difficulty is severe; monitor oxygenation continuously during any airway attempt and have a clear, rehearsed plan B/C before induction; communicate the anticipated difficulty to the full team and document findings for future anaesthetic encounters.
- Postoperative hypoxaemia: Supplemental oxygen and identification of the cause (atelectasis, aspiration, opioid-induced hypoventilation, pulmonary oedema, pulmonary embolism) is first-line; escalate to non-invasive or invasive ventilatory support if hypoxaemia is severe or worsening; monitor respiratory rate, oxygen saturation, and work of breathing closely in the early postoperative period, particularly in high-risk patients (obesity, sleep apnoea, opioid-sparing not achieved); investigate promptly rather than simply increasing oxygen if the cause is unclear.
- Postoperative delirium: Non-pharmacological reorientation strategies (consistent staff, orientation cues, sleep-wake cycle preservation, early mobilisation) are first-line; minimal use of sedatives, with low-dose antipsychotics reserved for severe agitation posing safety risk; monitor with a validated delirium screening tool serially, as delirium is frequently under-recognised, particularly the hypoactive subtype; identify and correct precipitants (pain, urinary retention, constipation, infection, medication side effects) actively rather than treating agitation alone.
- Epidural haematoma (post-neuraxial): Emergency MRI and surgical decompression is first-line and time-critical, as delay beyond 8-12 hours from symptom onset significantly worsens neurological recovery; monitor neurological status (motor/sensory function, bladder function) closely after any neuraxial procedure, with a low threshold for imaging if new or worsening deficit, back pain, or bladder/bowel dysfunction develops; risk is higher with anticoagulation, and timing of neuraxial procedures relative to anticoagulant dosing should follow established safety intervals.
- Local anaesthetic toxicity (mild): Stop the injection immediately and provide supportive monitoring is first-line; prepare lipid emulsion therapy proactively in case of progression to severe toxicity (seizures, cardiovascular collapse); monitor for evolving neurological (perioral tingling, tinnitus, agitation) and cardiovascular symptoms closely, as mild toxicity can progress rapidly; ensure lipid emulsion and resuscitation equipment are readily available wherever significant volumes of local anaesthetic are used.
- Postoperative wound infection: Wound care with drainage of collections is first-line for superficial infection; antibiotics guided by culture for deeper or systemic infection, escalating to surgical debridement for necrotising infection or failure to improve; monitor wound appearance, systemic signs of sepsis, and inflammatory markers; risk factors (diabetes, obesity, smoking, immunosuppression) should prompt closer surveillance and optimisation where modifiable.
- Perioperative myocardial infarction: Standard ACS management (antiplatelet therapy, anticoagulation, urgent revascularisation as indicated) adapted for the perioperative bleeding risk is first-line, with cardiology input essential given the competing risks of surgical bleeding versus ischaemia; monitor troponin and ECG serially in high-risk surgical patients, as presentation is often silent (masked by analgesia/sedation); balance antithrombotic intensity carefully against the surgical site and timing.
- Malignant hyperthermia (established): Immediate dantrolene administration is first-line and life-saving, alongside stopping all triggering agents and active cooling; escalate supportive care (hyperkalaemia correction, arrhythmia management, renal protection from myoglobinuria) in parallel; monitor core temperature, end-tidal CO2, and electrolytes continuously during the acute episode; screen family members for susceptibility once the index case is confirmed, and flag the diagnosis clearly for all future anaesthetics.
- Awareness under general anaesthesia (risk reduction): Depth-of-anaesthesia monitoring in high-risk cases (e.g. total intravenous anaesthesia, neuromuscular blockade, cardiac surgery) and adequate agent dosing is first-line prevention; monitor for risk factors (previous awareness, difficult airway requiring reduced induction dose, haemodynamic instability limiting anaesthetic depth) proactively; if awareness is reported postoperatively, take it seriously, document thoroughly, debrief the patient, and offer psychological support given the potential for post-traumatic symptoms.
- Postoperative hypotension: Fluid bolus and identification of the cause (bleeding, sepsis, anaesthetic residual effect, cardiac dysfunction) is first-line; escalate to vasopressor support and targeted treatment of the underlying cause if fluid-refractory; monitor blood pressure trend, urine output, and for concealed bleeding (particularly after abdominal/pelvic/orthopaedic surgery) rather than attributing hypotension to anaesthetic effect alone without adequate reassessment.
- Perioperative anaphylaxis: Immediate IM/IV adrenaline is first-line and time-critical, alongside stopping the likely triggering agent (commonly neuromuscular blockers, antibiotics, or chlorhexidine) and airway/circulatory support; escalate fluid resuscitation and consider glucagon if the patient is on beta-blockers and refractory to adrenaline; monitor closely for biphasic reactions over the following hours; send serum tryptase at the time of reaction and refer for allergy testing afterward to identify the culprit agent.
- Postoperative urinary retention: Bladder scan and catheterisation if significant retention is first-line; monitor for recurrent retention after catheter removal, particularly in older men or those with pre-existing prostatic disease, opioid use, or neuraxial anaesthesia (all of which increase risk); consider a trial without catheter with a defined plan for recatheterisation if retention recurs, and review opioid dosing as a contributing factor.
- Postoperative atelectasis: Incentive spirometry, early mobilisation, and adequate analgesia to allow deep breathing and coughing are first-line, particularly after upper abdominal or thoracic surgery; escalate to chest physiotherapy or non-invasive respiratory support for more significant atelectasis with hypoxaemia; monitor respiratory rate and oxygen saturation, and encourage sitting upright rather than supine positioning to aid lung expansion.
- High spinal block (accidental): Immediate airway and haemodynamic support (oxygen, ventilatory support if needed, vasopressors and fluids for hypotension/bradycardia) is first-line until the block recedes; monitor respiratory function and level of consciousness closely, as ascending block can progress to apnoea and loss of consciousness; reassure the patient once stable, as the experience can be frightening, and document the event for future anaesthetic planning.
- Perioperative hypothermia (prevention): Active warming (forced-air warmers, warmed IV fluids, and warmed theatre environment) throughout the perioperative period is first-line prevention, started before induction rather than only once hypothermia is established; monitor core temperature continuously in longer procedures; hypothermia increases bleeding, wound infection, and cardiac event risk, making proactive prevention more effective than reactive rewarming.
Nephrology
- Acute kidney injury (pre-renal): IV fluid resuscitation to restore renal perfusion first-line, with removal of nephrotoxic drugs (NSAIDs, ACE-I/ARB temporarily); escalate to renal replacement therapy for refractory hyperkalaemia, acidosis, or fluid overload; monitor urine output, creatinine trend, and volume status closely as over-resuscitation risks pulmonary oedema; in cirrhosis-related hepatorenal physiology, use albumin rather than crystalloid and consider terlipressin.
- Acute kidney injury (intrinsic, ATN): Supportive care (avoid further nephrotoxins, optimise haemodynamics) as no specific pharmacotherapy reverses established ATN; escalate to renal replacement therapy for refractory hyperkalaemia, acidosis, fluid overload, or uraemic symptoms; monitor daily renal function and electrolytes, as most ATN is reversible over 1-3 weeks; adjust all renally cleared drug doses during the injury and recovery phases.
- Acute kidney injury with hyperkalaemia: IV calcium gluconate for cardiac membrane stabilisation first-line if ECG changes present, alongside insulin-dextrose and salbutamol to shift potassium intracellularly; escalate to urgent dialysis for refractory or severe hyperkalaemia (>6.5-7 mmol/L) not responding to medical therapy; monitor ECG continuously and repeat potassium after each intervention, since shifting agents are temporising rather than eliminating; avoid potassium-retaining drugs until resolved.
- Chronic kidney disease (stage 3-4): ACE-I/ARB and SGLT2 inhibitor first-line for proteinuric CKD to slow progression, alongside blood pressure control and management of anaemia/mineral bone disease; escalate to nephrology referral and dialysis-access planning as eGFR approaches stage 5; monitor eGFR, potassium, and proteinuria every 3-6 months; adjust drug dosing for renal clearance and avoid nephrotoxins (NSAIDs, contrast where avoidable).
- End-stage renal disease: Renal replacement therapy (haemodialysis, peritoneal dialysis, or pre-emptive transplantation) is definitive, with transplantation preferred where feasible given superior survival and quality of life; monitor dialysis adequacy (Kt/V), anaemia, and mineral bone disease markers regularly; manage vascular access complications and cardiovascular risk aggressively, as cardiovascular disease is the leading cause of death; early transplant work-up improves access to pre-emptive transplantation.
- Nephrotic syndrome (adult, minimal change): High-dose oral corticosteroids first-line, with the majority achieving remission; escalate to calcineurin inhibitor or cyclophosphamide for steroid-resistant or frequently relapsing disease; monitor for remission by urine protein, and for steroid-related complications (glucose, bone density) on prolonged courses; prophylactic anticoagulation is considered in severe hypoalbuminaemia given high thrombosis risk.
- Focal segmental glomerulosclerosis: High-dose corticosteroids first-line, escalating to calcineurin inhibitors for steroid-resistant disease; consider rituximab or other steroid-sparing agents for relapsing/refractory disease; monitor proteinuria and renal function closely as FSGS has a higher risk of progression to ESRD than minimal change disease; genetic testing is warranted in familial or steroid-resistant paediatric-onset cases as it changes management away from immunosuppression.
- Rapidly progressive glomerulonephritis: Urgent high-dose IV corticosteroids plus cyclophosphamide or rituximab first-line, as delay risks irreversible renal failure; add plasma exchange for anti-GBM disease or severe ANCA-vasculitis with pulmonary haemorrhage; monitor renal function daily during induction and serial ANCA/anti-GBM titres; renal biopsy should not be delayed as it guides both diagnosis and prognosis.
- Post-streptococcal glomerulonephritis: Supportive care (fluid/salt restriction, antihypertensives, diuretics for oedema) is first-line, as the condition is generally self-limiting, especially in children; monitor renal function, complement (C3) normalisation, and blood pressure; treat any persistent streptococcal infection with antibiotics; adults have a less favourable prognosis and a lower threshold for renal biopsy if recovery is incomplete.
- Diabetic nephropathy: ACE-I/ARB and SGLT2 inhibitor first-line for reno-protection regardless of blood pressure, with glycaemic and blood pressure optimisation; add a non-steroidal mineralocorticoid antagonist (finerenone) for residual albuminuria risk; monitor urine albumin-creatinine ratio and eGFR at least annually; avoid combining ACE-I and ARB together due to hyperkalaemia/AKI risk without added benefit.
- Polycystic kidney disease: Blood pressure control (ACE-I/ARB first-line) and tolvaptan for select patients with rapidly progressive disease to slow cyst growth; escalate to renal replacement therapy/transplant as ESRD develops; monitor renal function, blood pressure, and screen for intracranial aneurysms in those with a family history of aneurysm/SAH; genetic counselling is relevant given autosomal dominant inheritance and screening of at-risk relatives.
- Renal artery stenosis: Medical therapy (ACE-I/ARB with caution, statin, antiplatelet) is first-line for atherosclerotic disease unless refractory hypertension or declining renal function; angioplasty/stenting is preferred and often curative for fibromuscular dysplasia; monitor renal function and potassium closely after starting ACE-I/ARB given bilateral disease risk of AKI; avoid ACE-I/ARB in bilateral stenosis or stenosis to a solitary functioning kidney.
- Renal tubular acidosis: Oral alkali replacement (sodium bicarbonate or citrate) is first-line across all types to correct acidosis and prevent bone/growth complications; potassium supplementation or restriction depends on subtype (hypokalaemic type 1/2 vs hyperkalaemic type 4); monitor serum bicarbonate, potassium, and growth in children; identify and treat the underlying cause (autoimmune, drug-induced, obstructive uropathy for type 4).
- Hyponatraemia (severe, symptomatic): Hypertonic (3%) saline bolus first-line for severe symptomatic hyponatraemia (seizures, coma) to acutely raise sodium; correct no faster than 8-10 mmol/L in 24 hours to avoid osmotic demyelination syndrome; monitor sodium every 2-4 hours during active correction; in chronic hyponatraemia or alcoholism/malnutrition, correct even more cautiously given higher demyelination risk.
- Hyperkalaemia (severe, ECG changes): IV calcium gluconate immediately for membrane stabilisation given ECG changes, followed by insulin-dextrose and salbutamol to shift potassium intracellularly; escalate to urgent dialysis if refractory or in severe AKI/ESRD; monitor continuous ECG and repeat potassium after each measure; identify and stop causative drugs (ACE-I/ARB, potassium-sparing diuretics, NSAIDs).
- Metabolic acidosis (severe): Treat the underlying cause (fluid resuscitation for lactic acidosis, insulin for DKA, dialysis for toxin-related acidosis) rather than bicarbonate alone; reserve IV bicarbonate for severe acidaemia (pH <7.1-7.2) or specific indications (severe hyperkalaemia, TCA overdose); monitor arterial blood gas and anion gap trend to guide ongoing therapy; distinguish anion-gap from non-anion-gap causes early, as this directs the diagnostic work-up.
- Contrast-induced nephropathy (prevention): IV isotonic saline hydration pre- and post-procedure is the primary preventive first-line measure in at-risk patients; minimise contrast volume and use iso-osmolar/low-osmolar agents; monitor renal function 48-96 hours post-procedure in high-risk patients (pre-existing CKD, diabetes, dehydration); hold nephrotoxic drugs (NSAIDs, and consider metformin) periprocedurally in significant renal impairment.
- Renal transplant rejection (acute): Pulse IV corticosteroids first-line for acute cellular rejection, escalating to T-cell depleting antibody therapy (ATG) for steroid-resistant or severe rejection; antibody-mediated rejection requires plasma exchange, IVIG, and/or rituximab; monitor graft function (creatinine), donor-specific antibodies, and biopsy for classification which determines specific therapy; balance immunosuppression intensification against infection risk.
- Hepatorenal syndrome: IV albumin plus a splanchnic vasoconstrictor (terlipressin, or noradrenaline in ICU) first-line to improve renal perfusion; renal replacement therapy as a bridge to liver transplant in appropriate candidates, since transplant is the only definitive cure; monitor renal function and haemodynamics closely; exclude other causes of AKI (hypovolaemia, intrinsic renal disease) before diagnosing HRS, as it is a diagnosis of exclusion.
- Peritoneal dialysis-associated peritonitis: Empirical intraperitoneal antibiotics covering both Gram-positive and Gram-negative organisms first-line, narrowed once culture available; catheter removal is required for refractory infection, fungal peritonitis, or relapsing episodes; monitor dialysate clarity/cell count response at 48-72 hours; fungal peritonitis carries high catheter loss and mortality risk and warrants early surgical/nephrology involvement.
- Membranoproliferative glomerulonephritis: Treat the underlying cause first (infection, monoclonal gammopathy, complement dysregulation, autoimmune disease), as classification now centres on immune-complex versus complement-mediated disease; immunosuppression (steroids +/- other agents) or complement inhibitors used for complement-mediated (C3 glomerulopathy) disease; monitor complement levels, renal function, and proteinuria; renal biopsy with immunofluorescence/EM is essential to guide subtype-specific therapy.
- Alport syndrome: ACE-I/ARB first-line to reduce proteinuria and slow progression once microalbuminuria is detected, even before overt renal impairment; genetic counselling given X-linked/autosomal inheritance patterns; monitor renal function, hearing, and ophthalmological findings (lenticonus) as part of the syndromic triad; renal transplant is the definitive treatment for ESRD and is not complicated by disease recurrence in the graft.
- Thin basement membrane disease: Reassurance and monitoring alone for isolated microscopic haematuria with normal renal function and no proteinuria, as prognosis is generally excellent; add ACE-I/ARB if proteinuria or hypertension develops; monitor renal function and proteinuria periodically, as a minority progress; distinguish from Alport syndrome via family history and genetic testing given differing prognosis and screening implications for relatives.
- Fabry disease (renal): Enzyme replacement therapy (agalsidase) or oral chaperone therapy (migalastat, in amenable mutations) first-line to slow renal, cardiac, and cerebrovascular disease progression; ACE-I/ARB for proteinuria as adjunctive renoprotection; monitor renal function, proteinuria, cardiac MRI, and neuropathic pain symptoms; genetic counselling and family screening are important given X-linked inheritance.
- Cast nephropathy (myeloma kidney): Urgent treatment of the underlying myeloma (bortezomib-based regimen) to rapidly reduce free light chains is first-line, alongside aggressive IV hydration; escalate to high-cut-off haemodialysis for severe AKI to remove light chains, particularly if renal recovery potential exists; monitor free light chain levels and renal function closely; avoid nephrotoxins and correct hypercalcaemia, which commonly coexists and worsens renal injury.
- Analgesic nephropathy: Complete cessation of the causative analgesic (combination NSAID/phenacetin-type analgesics) is the essential first-line step, as continued use drives progression; supportive management of resulting CKD; monitor renal function and screen for urothelial malignancy given increased risk with phenacetin exposure; papillary necrosis may cause obstruction requiring urological intervention.
- Acute interstitial nephritis (drug-induced): Prompt withdrawal of the causative drug (commonly antibiotics, NSAIDs, PPIs) is first-line and often sufficient for recovery; add corticosteroids for severe or persistent renal impairment despite drug withdrawal; monitor renal function for recovery over days to weeks; a careful drug history and eosinophilia/urinary eosinophils support diagnosis though absence does not exclude it.
- Uric acid nephropathy: IV hydration and urine alkalinisation first-line, with rasburicase for tumour-lysis-associated hyperuricaemia given rapid and potent uric-acid-lowering effect; allopurinol used for prevention rather than acute treatment; monitor renal function and uric acid levels closely during tumour lysis risk periods; avoid rasburicase in G6PD deficiency due to haemolysis risk.
- Nephrolithiasis (recurrent, metabolic evaluation): Increased fluid intake and dietary modification (sodium/oxalate restriction, adequate calcium) first-line for prevention after metabolic work-up (24-hour urine studies) identifies risk factors; add thiazides for hypercalciuria or citrate for hypocitraturia/uric acid stones based on stone composition; monitor recurrence with periodic imaging; underlying causes (hyperparathyroidism, RTA, bowel disease) should be specifically treated.
- Medullary sponge kidney: Conservative management (hydration, treatment of any hypercalciuria/hypocitraturia) is first-line as most cases are asymptomatic or present with recurrent stones/UTI; escalate to standard stone management (lithotripsy, ureteroscopy) for symptomatic calculi; monitor for recurrent UTIs and nephrocalcinosis; renal function is usually preserved and prognosis is generally good.
- Renal vein thrombosis: Anticoagulation is first-line, particularly in the setting of nephrotic syndrome (which predisposes via urinary antithrombin loss); thrombolysis or thrombectomy reserved for bilateral involvement with acute renal failure; monitor renal function and treat the underlying nephrotic syndrome to reduce ongoing thrombotic risk; screen for pulmonary embolism given high co-occurrence.
- Cholesterol embolisation syndrome: Supportive management (renal support, blood pressure control, statin therapy) as no specific reversal treatment exists; avoid further vascular procedures/anticoagulation manipulation that may provoke further embolisation, though this must be balanced against the indication for anticoagulation; monitor renal function, skin findings (livedo reticularis, blue toe syndrome), and eosinophilia; typically follows vascular intervention or anticoagulation/thrombolysis in atherosclerotic patients.
- Anti-GBM disease (Goodpasture syndrome): Urgent plasma exchange plus high-dose corticosteroids and cyclophosphamide is first-line, especially with pulmonary haemorrhage or severe renal failure, as rapid treatment improves renal and pulmonary outcomes; monitor anti-GBM titres, renal function, and for pulmonary haemorrhage; renal biopsy should not be delayed; unlike ANCA vasculitis, relapse is uncommon once treated, so long-term immunosuppression is usually not required after remission.
- IgA vasculitis nephritis: Supportive care (ACE-I/ARB for proteinuria, blood pressure control) first-line for mild disease; escalate to corticosteroids +/- immunosuppression for crescentic or nephrotic-range proteinuria; monitor renal function and urinalysis, as most paediatric cases resolve while adult-onset carries higher renal risk; screen for other organ involvement (GI, joint, skin) as part of the systemic vasculitis.
- Renal amyloidosis: Treat the underlying clonal/inflammatory process driving amyloid deposition (chemotherapy for AL amyloidosis, anti-inflammatory control for AA amyloidosis) as the primary first-line strategy; supportive ACE-I/ARB for proteinuria; monitor renal function, proteinuria, and cardiac involvement (which drives prognosis in AL amyloidosis); renal transplant may be considered once the underlying disease is controlled.
- Bartter syndrome: Potassium and salt supplementation first-line, adding a potassium-sparing diuretic (amiloride/spironolactone) and NSAID (indomethacin) to reduce urinary potassium/prostaglandin-mediated losses; monitor electrolytes closely, particularly in infancy where growth and volume status must be tracked; genetic subtype influences severity and prognosis, with antenatal forms being most severe.
- Gitelman syndrome: Oral magnesium and potassium supplementation first-line, as hypomagnesaemia often limits potassium correction; add potassium-sparing diuretics for refractory hypokalaemia; monitor electrolytes regularly, as this is generally a lifelong but milder condition than Bartter syndrome; distinguish from diuretic misuse/bulimia via urinary chloride and diuretic screening when the presentation is ambiguous.
- Nephrogenic diabetes insipidus: Thiazide diuretics paradoxically reduce urine output first-line by inducing mild volume depletion that enhances proximal water reabsorption, combined with low-sodium/low-protein diet; identify and stop the causative drug (commonly lithium) where possible; monitor serum sodium and urine output, and ensure free access to water to prevent dangerous hypernatraemia; amiloride can reduce lithium-induced NDI specifically by blocking lithium entry into collecting duct cells.
- Dialysis catheter-related bacteraemia: Empirical IV antibiotics covering Gram-positive organisms (including MRSA) plus Gram-negative cover, adjusted once cultures return; catheter removal is generally required for tunnelled catheter infection with severe sepsis, persistent bacteraemia, or fungal infection, though catheter salvage with antibiotic lock therapy may be tried in stable uncomplicated cases; monitor blood cultures for clearance and for metastatic infection (endocarditis, osteomyelitis) with persistent bacteraemia.
- Renal transplant chronic rejection: Optimisation of maintenance immunosuppression and aggressive control of cardiovascular risk factors first-line, as chronic rejection has limited reversibility; monitor graft function trend, proteinuria, and donor-specific antibodies; biopsy to distinguish chronic antibody-mediated rejection from other causes of graft dysfunction (calcineurin inhibitor toxicity, recurrent disease) as management differs; early referral for re-transplant work-up if graft failure appears likely.
Urology
- Benign prostatic hyperplasia: Alpha-blocker first-line for symptomatic relief, adding a 5-alpha-reductase inhibitor for larger prostates or to reduce progression risk; escalate to surgery (TURP or newer minimally invasive techniques) for refractory symptoms, recurrent retention, or complications (renal impairment, recurrent haematuria/UTI); monitor PSA and renal function, and review for orthostatic hypotension on alpha-blockers, particularly in the elderly.
- Acute urinary retention: Immediate urethral (or suprapubic if urethral catheterisation fails) catheterisation is first-line; start an alpha-blocker before a trial without catheter to improve success rate; monitor for post-obstructive diuresis and renal function after decompression; identify and treat the precipitant (BPH, constipation, medications, infection, neurological cause).
- Testicular torsion: Immediate surgical exploration and detorsion is definitive, as testicular salvage is time-critical (best outcomes within 6h of symptom onset); manual detorsion can be attempted as a temporising measure while awaiting theatre but does not replace surgical fixation; bilateral orchidopexy is performed to prevent future torsion, given anatomical predisposition is often bilateral; monitor for testicular viability at surgery, with orchidectomy if non-viable.
- Epididymo-orchitis: Empirical antibiotics targeting likely organism (chlamydia/gonorrhoea in young sexually active men, coliforms in older men/those with BPH) first-line, guided by local protocols and STI screening; analgesia and scrotal support as adjuncts; monitor for abscess formation or failure to improve, prompting imaging; testicular torsion must be excluded urgently in any acute scrotal pain given differing time-critical management.
- Renal/ureteric colic: NSAIDs first-line for analgesia (as effective as opioids with fewer side effects); most stones <5-6mm pass spontaneously with medical expulsive therapy (alpha-blocker); escalate to urgent decompression (stent/nephrostomy) for infected obstructed system (surgical emergency) or refractory pain/renal impairment; monitor for fever suggesting infected obstruction, and stone size/position on imaging to guide need for intervention (lithotripsy, ureteroscopy).
- Staghorn calculus: Percutaneous nephrolithotomy first-line given large stone burden, sometimes combined with shockwave lithotripsy for residual fragments; treat and prevent recurrent infection, as these stones are often infection-related (struvite); monitor renal function and for recurrence with metabolic stone workup; untreated staghorn calculi carry a significant risk of progressive renal damage and sepsis.
- Bladder outlet obstruction: Catheterisation for acute decompression first-line, then treat the underlying cause (BPH, stricture, prolapse) definitively; monitor renal function and for post-obstructive diuresis after decompression; urodynamic studies help clarify the obstruction mechanism when the cause is unclear, guiding targeted intervention.
- Priapism (ischaemic): Immediate aspiration of the corpora plus intracavernosal phenylephrine is first-line, as this is a urological emergency where delay risks permanent erectile dysfunction; escalate to surgical shunting if aspiration/phenylephrine fails; monitor for resolution and treat the underlying cause (sickle cell disease, medications); distinguish from non-ischaemic (high-flow) priapism, which is not an emergency and managed differently.
- Paraphimosis: Manual reduction with analgesia/lubrication first-line, using techniques to reduce oedema (compression, granulated sugar) if simple reduction fails; escalate to emergency dorsal slit or circumcision if manual reduction is unsuccessful, given risk of glans ischaemia; monitor for recurrence and arrange elective circumcision to prevent it.
- Fournier's gangrene: Urgent aggressive surgical debridement plus broad-spectrum IV antibiotics is definitive and time-critical, as delay significantly increases mortality; repeat debridement often needed until the infection is controlled; monitor for sepsis/multi-organ dysfunction and diabetes (a common predisposing factor requiring concurrent management); reconstructive surgery is deferred until infection has resolved.
- Vesicoureteric reflux (paediatric): Prophylactic low-dose antibiotics and observation first-line for lower-grade reflux, as many children outgrow it; escalate to surgical/endoscopic correction for high-grade reflux, breakthrough infections, or renal scarring; monitor for recurrent UTIs and renal scarring with imaging (DMSA scan); most reflux resolves spontaneously with growth, favouring a conservative approach where possible.
- Neurogenic bladder: Clean intermittent self-catheterisation is first-line for most cases to protect renal function and manage incontinence, alongside anticholinergics/beta-3 agonists for detrusor overactivity; escalate to botulinum toxin injection or surgical reconstruction for refractory cases; monitor renal function, bladder pressures (urodynamics), and for recurrent UTI given high renal complication risk if unmanaged.
- Stress urinary incontinence: Pelvic floor muscle training first-line, which has good evidence particularly in postpartum women; escalate to surgical options (mid-urethral sling, colposuspension) for refractory symptoms significantly affecting quality of life; monitor symptom severity and impact on quality of life to guide escalation; weight loss and treatment of chronic cough (smoking cessation) are useful adjuncts.
- Urethral stricture: Urethral dilatation or internal urethrotomy first-line for short simple strictures, though recurrence is common; urethroplasty (open reconstruction) offers higher long-term success for longer/recurrent strictures and is preferred where expertise allows; monitor for recurrence with flow rates/follow-up cystoscopy; intermittent self-dilatation may be used to maintain patency after initial treatment in select cases.
- Hydrocele: Observation first-line in infants, as most congenital hydroceles resolve spontaneously by age 1-2; surgical repair (hydrocelectomy) for persistent, large, or symptomatic hydroceles, and in adults where secondary causes (tumour, infection) have been excluded; monitor for resolution in infants and exclude an underlying testicular pathology with ultrasound in adult-onset hydrocele.
- Varicocele (symptomatic/infertility): Observation for asymptomatic varicoceles with normal semen parameters; surgical or radiological (embolisation) repair for pain, testicular atrophy, or infertility with abnormal semen parameters; monitor semen analysis and testicular size/growth in adolescents; repair does not guarantee improved fertility outcomes, and this should be discussed when counselling.
- Interstitial cystitis/bladder pain syndrome: Patient education, dietary modification, and bladder training first-line, given the chronic relapsing nature of the condition; escalate to oral agents (amitriptyline, pentosan polysulfate) or intravesical therapy for refractory symptoms; monitor symptom severity and quality of life, as objective markers correlate poorly with symptoms; exclude other causes of chronic pelvic/bladder pain (infection, malignancy) before committing to this diagnosis.
- Renal cell carcinoma (metastatic): Systemic therapy (tyrosine kinase inhibitors combined with immune checkpoint inhibitors) first-line for metastatic disease, representing a major shift from older cytokine-based therapy; cytoreductive nephrectomy considered in select patients with good performance status and oligometastatic disease; monitor treatment response with imaging and for immune-related adverse effects on checkpoint inhibitors; palliative radiotherapy for symptomatic metastases (bone, brain).
- Urothelial carcinoma (non-muscle-invasive bladder): Transurethral resection of bladder tumour (TURBT) first-line, followed by intravesical therapy (BCG for high-risk, mitomycin for intermediate-risk) to reduce recurrence/progression; monitor with regular cystoscopic surveillance given high recurrence rates; escalate to cystectomy for BCG-refractory high-risk disease or progression to muscle-invasive disease.
- Penile carcinoma: Organ-preserving surgery (wide local excision, glansectomy) first-line for early localised disease where feasible, with partial/total penectomy for more advanced disease; assess and manage inguinal lymph nodes based on risk stratification, as nodal status is the key prognostic factor; monitor for local and nodal recurrence; delayed presentation (often due to embarrassment) worsens prognosis, so early referral for any persistent penile lesion is important.
- Peyronie's disease: Observation during the acute inflammatory phase (up to 12-18 months), as spontaneous improvement can occur; intralesional collagenase or traction therapy for the stable phase with bothersome curvature; surgical correction (plication or grafting) for stable, severe deformity causing functional impairment; monitor for progression during the acute phase before considering surgery, which is deferred until stability is reached.
- Erectile dysfunction: Phosphodiesterase-5 inhibitors first-line, alongside treatment of underlying cardiovascular/metabolic risk factors which often coexist; escalate to intracavernosal injection, vacuum devices, or penile prosthesis for PDE5-inhibitor failure; monitor cardiovascular risk, as ED can be an early marker of systemic vascular disease warranting cardiovascular risk assessment; avoid PDE5 inhibitors with nitrates given risk of severe hypotension.
- Male infertility (varicocele-related): Varicocelectomy considered for clinically significant varicocele with abnormal semen parameters and otherwise unexplained infertility; assisted reproduction (IVF/ICSI) as an alternative or adjunct, particularly with a female partner factor or severe male factor; monitor semen analysis post-repair, noting improvement can take several months given the sperm production cycle; counsel realistically on the variable evidence for fertility benefit from repair.
- Cryptorchidism: Orchidopexy (ideally by age 12-18 months) is first-line to optimise fertility potential and allow surveillance, and to reduce (though not eliminate) malignancy risk; hormonal therapy has a limited/lower success rate compared to surgery; monitor for testicular malignancy risk long-term even after successful orchidopexy, with patient education on self-examination; spontaneous descent is unlikely after 6 months of age.
- Posterior urethral valves: Immediate bladder catheterisation for decompression first-line in the newborn with suspected diagnosis, followed by endoscopic valve ablation once stable; monitor renal function closely, as this is a leading cause of paediatric renal failure if diagnosis/treatment is delayed; long-term surveillance for chronic kidney disease and bladder dysfunction is required even after successful ablation.
- Pelvi-ureteric junction obstruction: Observation with serial imaging first-line for mild/stable hydronephrosis, particularly if asymptomatic and renal function preserved; pyeloplasty (open, laparoscopic, or robotic) for symptomatic obstruction, deteriorating renal function, or worsening hydronephrosis; monitor differential renal function with nuclear renography to guide the decision to intervene.
- Urethral trauma (pelvic fracture-associated): Suprapubic catheterisation is first-line if urethral injury is suspected (blood at meatus, inability to void) rather than attempting urethral catheterisation, which risks converting a partial to complete injury; delayed urethroplasty once the patient is stable and pelvic injuries have healed is preferred over immediate primary realignment in most complete disruptions; monitor for stricture formation, a common long-term complication requiring surveillance.
- Bladder trauma (extraperitoneal rupture): Conservative management with catheter drainage first-line, as most extraperitoneal ruptures heal without surgery; surgical repair reserved for concomitant pelvic fracture fixation, bone fragments in the bladder, or failure of conservative management; monitor with repeat cystogram before catheter removal to confirm healing; intraperitoneal rupture, by contrast, requires surgical repair given peritonitis risk.
- Renal trauma (blunt, high-grade): Non-operative management with close monitoring first-line for haemodynamically stable patients, even with high-grade injury, given the kidney's capacity to heal; angioembolisation for ongoing bleeding/pseudoaneurysm; surgery (repair or nephrectomy) reserved for haemodynamic instability or failure of conservative/angiographic management; monitor haemoglobin, haemodynamics, and repeat imaging to assess for delayed complications (urinoma, delayed bleeding).
- Urosepsis (obstructed, infected system): Emergency decompression (nephrostomy or ureteric stent) alongside broad-spectrum IV antibiotics and resuscitation is definitive, as source control is essential and antibiotics alone are inadequate with an obstructed infected system; monitor for septic shock requiring escalation to critical care; treat the underlying obstruction (stone, stricture, tumour) definitively once the acute sepsis has resolved.
- Chronic pelvic pain syndrome (male): Multimodal management (alpha-blockers, pelvic floor physiotherapy, and pain management strategies) first-line, given the limited efficacy of antibiotics in most cases despite historical practice; a trial of antibiotics is reasonable if an infective component cannot be excluded; monitor symptom scores and quality of life, as objective findings are often absent; psychological support/counselling has a role given the chronic, often relapsing course.
- Overactive bladder: Bladder training and lifestyle modification (fluid/caffeine reduction) first-line; escalate to antimuscarinics or beta-3 agonists (mirabegron, preferred in the elderly given lower anticholinergic burden) for inadequate response; further escalate to intravesical botulinum toxin or sacral neuromodulation for refractory symptoms; monitor for anticholinergic side effects (dry mouth, constipation, cognitive impact) particularly in older patients.
Critical Care & Emergency
- Anaphylactic shock: Immediate IM adrenaline (anterolateral thigh) is first-line and should not be delayed for IV access; high-flow oxygen, IV fluids, and removal of the trigger alongside; repeat adrenaline every 5 minutes for inadequate response, escalating to IV adrenaline infusion for refractory shock; monitor for biphasic reaction requiring observation for several hours after resolution; antihistamines/steroids are adjuncts only and must never substitute for adrenaline.
- Cardiogenic pulmonary oedema: IV diuretics, nitrates, and non-invasive ventilation (CPAP) first-line; inotropic support for hypotensive patients unable to tolerate vasodilators; monitor oxygenation, urine output, and renal function on diuresis; identify and treat the precipitant (ACS, arrhythmia, valve failure), which guides definitive management beyond symptomatic decongestion.
- Acute respiratory failure (type 1): High-flow oxygen (or non-invasive/high-flow nasal therapy) first-line to correct hypoxaemia; identify and treat the underlying cause (pneumonia, pulmonary oedema, PE, ARDS); escalate to invasive ventilation for failure of non-invasive support or deteriorating respiratory effort; monitor oxygen saturation, work of breathing, and arterial blood gases serially to guide escalation.
- Acute respiratory failure (type 2): Controlled oxygen therapy (avoiding hyperoxia which worsens hypercapnia via V/Q mismatch and reduced hypoxic drive) plus non-invasive ventilation (BiPAP) first-line, particularly effective in COPD exacerbation; escalate to invasive ventilation for NIV failure or contraindication; monitor arterial CO2 and pH trend, and treat the underlying cause (COPD exacerbation, neuromuscular weakness, sedative overdose).
- Multi-organ dysfunction syndrome: Source control and treatment of the underlying trigger (sepsis, trauma, pancreatitis) first-line, alongside organ-support therapies (ventilation, vasopressors, renal replacement therapy) tailored to the failing systems; monitor organ function scores (SOFA) serially to track trajectory; early, aggressive resuscitation and source control reduce progression risk; nutritional and glycaemic support are important supportive adjuncts.
- Massive haemorrhage: Activation of a massive transfusion protocol with balanced blood product ratios (red cells, plasma, platelets) first-line, alongside rapid haemorrhage control (surgical, interventional radiology, or tranexamic acid if within the appropriate window for trauma); monitor coagulation status (including viscoelastic testing where available) to guide targeted product replacement; avoid excessive crystalloid, which worsens coagulopathy and dilution.
- Burns (major, >20% TBSA): Aggressive fluid resuscitation (formula-guided, e.g. Parkland) titrated to urine output first-line, alongside airway assessment for inhalational injury which may need early intubation; early burns centre transfer and surgical debridement/grafting for full-thickness burns; monitor for compartment syndrome (escharotomy if needed), infection, and evolving fluid requirements; analgesia and nutritional support are critical given high catabolic demand.
- Electrical injury: Cardiac monitoring for arrhythmia first-line, as electrical injury can cause immediate or delayed cardiac events; assess for deep tissue/muscle injury (often underestimated from surface appearance) and check creatine kinase/myoglobin for rhabdomyolysis; monitor renal function and urine output given AKI risk from myoglobinuria; high-voltage injury requires more extensive monitoring and a lower threshold for admission than low-voltage domestic injury.
- Drowning/near-drowning: Airway, breathing, and circulation support with oxygen/ventilation first-line, as hypoxia is the primary insult; observe for at least 4-6 hours even in asymptomatic patients given risk of delayed pulmonary complications; monitor for aspiration pneumonitis, ARDS, and hypothermia; cervical spine precautions if diving/trauma mechanism is possible.
- Hypothermia (severe): Careful rewarming (active external for moderate, active internal/extracorporeal for severe with cardiac instability) first-line, handling the patient gently to avoid triggering ventricular fibrillation; withhold defibrillation/drugs below a core temperature threshold per ACLS hypothermia algorithm, as they are often ineffective until rewarmed; monitor core temperature and cardiac rhythm continuously; 'not dead until warm and dead' guides prolonged resuscitation efforts in cardiac arrest.
- Heat exhaustion: Rapid cooling (evaporative/convective methods) and oral or IV rehydration first-line, as the core temperature is not as critically elevated as in heat stroke; monitor for progression to heat stroke (altered mental status, core temp >40°C) requiring more aggressive cooling; electrolyte correction (particularly sodium) as needed; rest and avoidance of further heat exposure until symptoms fully resolve.
- Carbon monoxide poisoning: High-flow 100% oxygen first-line, which accelerates carboxyhaemoglobin dissociation; hyperbaric oxygen for severe poisoning (loss of consciousness, significant neurological/cardiac features, pregnancy) where available within the appropriate window; monitor carboxyhaemoglobin levels and neurological status, including for delayed neuropsychiatric sequelae; identify and address the source to prevent re-exposure/co-exposure of others.
- Cyanide poisoning: Hydroxocobalamin (or sodium thiosulfate/nitrites as alternatives) first-line, given promptly on clinical suspicion (severe metabolic acidosis with disproportionately normal oxygen saturation) rather than awaiting confirmatory levels; 100% oxygen and supportive care alongside; monitor lactate (markedly elevated) as a useful marker of severity and response to treatment; consider co-exposure to carbon monoxide in smoke inhalation given overlapping presentations.
- Tricyclic antidepressant overdose: IV sodium bicarbonate first-line for cardiotoxicity (widened QRS, arrhythmia, hypotension), which both reverses sodium channel blockade and drives serum alkalinisation; avoid class Ia/Ic antiarrhythmics which worsen sodium channel blockade; monitor ECG (QRS width predicts seizure/arrhythmia risk) continuously; benzodiazepines for seizures, and IV lipid emulsion considered for refractory cardiovascular collapse.
- Paracetamol overdose: N-acetylcysteine first-line, guided by the paracetamol level plotted against a treatment nomogram (or given empirically for staggered/uncertain-time overdoses); activated charcoal if presenting within 1 hour of a significant ingestion; monitor liver function, INR, and renal function serially, as these guide need for liver unit referral; refer for transplant assessment using validated criteria (King's College) if acute liver failure develops.
- Salicylate poisoning: IV fluids and urinary alkalinisation (sodium bicarbonate) first-line to enhance renal elimination; haemodialysis for severe poisoning (very high levels, renal failure, severe acidosis, altered mental status, pulmonary oedema); monitor salicylate levels serially (can continue rising after ingestion), acid-base status (classically mixed respiratory alkalosis/metabolic acidosis), and glucose; avoid intubation without careful ventilation strategy, as impaired compensatory hyperventilation can precipitate severe acidaemia.
- Benzodiazepine overdose: Supportive care (airway protection, monitoring) first-line, as isolated benzodiazepine overdose is rarely fatal; flumazenil reversal used cautiously and selectively, avoided in chronic benzodiazepine users or mixed overdose (particularly with tricyclics) given seizure risk from precipitated withdrawal; monitor respiratory status and level of consciousness; co-ingestants (opioids, alcohol) significantly increase risk and change management priorities.
- Digoxin toxicity: Digoxin-specific antibody fragments (DigiFab) first-line for significant toxicity (life-threatening arrhythmia, severe hyperkalaemia, high levels); correct electrolytes cautiously, avoiding calcium administration for hyperkalaemia in digoxin toxicity given historical concern for worsening cardiac toxicity; monitor ECG for characteristic arrhythmias (bidirectional VT, various blocks) and potassium level, a key severity marker in acute toxicity; renal impairment predisposes to toxicity at therapeutic doses given renal clearance.
- Beta-blocker overdose: IV glucagon first-line (bypasses beta-receptor blockade to increase cAMP), alongside atropine and inotropic/vasopressor support for refractory bradycardia/hypotension; high-dose insulin-euglycaemia therapy for severe refractory cardiovascular toxicity; monitor ECG, glucose (on insulin therapy), and haemodynamics closely; distinguish from calcium channel blocker overdose where possible, as management overlaps but glucagon is more specific to beta-blockade.
- Calcium channel blocker overdose: IV calcium first-line to help overcome blockade, alongside high-dose insulin-euglycaemia therapy which is now considered a mainstay for refractory shock; glucagon and vasopressors as adjuncts; monitor glucose and potassium closely on high-dose insulin therapy, and ECG/haemodynamics continuously; lipid emulsion therapy considered for cardiovascular collapse refractory to other measures.
- Traumatic haemorrhagic shock: Damage control resuscitation (permissive hypotension until haemorrhage control, balanced blood products, minimising crystalloid) first-line, alongside rapid identification and control of the bleeding source (surgical or interventional radiology); tranexamic acid within 3 hours of injury reduces mortality; monitor for the lethal triad (coagulopathy, acidosis, hypothermia) and correct proactively; massive transfusion protocol activation for ongoing significant blood loss.
- Tension pneumothorax (traumatic): Immediate needle decompression (or finger thoracostomy) is first-line and should not await imaging confirmation in a haemodynamically unstable patient, as this is a clinical diagnosis in extremis; definitive chest tube insertion follows decompression; monitor for re-accumulation and for the underlying injury requiring further management; bilateral tension pneumothorax should be considered in traumatic cardiac arrest with no response to initial measures.
- Cardiac arrest (shockable rhythm): Immediate defibrillation integrated with high-quality CPR (minimal interruption) is first-line per ACLS algorithm for VF/pulseless VT; adrenaline and amiodarone given per protocol for refractory rhythms; identify and treat reversible causes (H's and T's) throughout; monitor end-tidal CO2 as a marker of CPR quality and return of spontaneous circulation; post-resuscitation care (targeted temperature management, urgent coronary angiography if cardiac cause suspected) follows ROSC.
- Cardiac arrest (non-shockable rhythm): High-quality CPR with adrenaline every 3-5 minutes is first-line for PEA/asystole, with defibrillation not indicated; aggressively search for and treat reversible causes (H's and T's), as these carry a worse prognosis without identification and correction; monitor end-tidal CO2 and rhythm changes (may convert to a shockable rhythm requiring reassessment); post-resuscitation care follows the same principles as for shockable arrests once ROSC achieved.
- Anaphylactoid transfusion reaction: Immediate cessation of the transfusion first-line, alongside supportive management as for anaphylaxis (IM adrenaline for significant reactions, antihistamines, fluids); monitor for progression and send the unit/patient sample back to the blood bank for investigation; distinguish from other transfusion reactions (febrile non-haemolytic, acute haemolytic, TRALI) as management and subsequent transfusion precautions differ significantly.
- Acute mountain sickness: Halt ascent and allow acclimatisation first-line for mild symptoms, with descent for worsening or severe symptoms; acetazolamide for prophylaxis/treatment of mild-moderate symptoms; monitor for progression to high-altitude pulmonary or cerebral oedema (worsening dyspnoea at rest, ataxia, altered mental status), which mandate immediate descent regardless of other measures; graded ascent is the most effective preventive strategy.
- High-altitude pulmonary oedema: Immediate descent is the definitive treatment and should not be delayed; supplemental oxygen and nifedipine as adjuncts/bridging measures if descent is delayed (e.g. by weather); portable hyperbaric bag as a temporising measure if descent is not immediately possible; monitor oxygen saturation and respiratory status closely; this can be rapidly fatal without prompt descent, so err on the side of early evacuation.
- High-altitude cerebral oedema: Immediate descent plus dexamethasone is first-line, as this is a life-threatening emergency; supplemental oxygen and portable hyperbaric bag as bridging measures if descent is delayed; monitor neurological status (ataxia, confusion, progressing to coma) closely; this represents a progression of acute mountain sickness and mandates urgent evacuation regardless of other symptoms.
- Decompression sickness: Immediate 100% oxygen and urgent recompression therapy (hyperbaric oxygen) is definitive, as delay worsens neurological outcomes; IV fluids for haemoconcentration; monitor neurological and joint symptoms closely, and avoid air travel/further altitude exposure until fully resolved; type II (neurological) decompression sickness requires the most urgent recompression given risk of permanent deficit.
- Envenomation (scorpion sting, severe): Antivenom first-line for severe systemic envenomation (autonomic storm, cardiovascular/respiratory compromise), alongside supportive management of pain and autonomic symptoms; monitor for cardiac (myocarditis, arrhythmia) and pulmonary (oedema) complications, particularly in children who are at higher risk of severe envenomation; local wound care and tetanus status review as adjuncts.
- Black widow spider envenomation: Analgesia and supportive care first-line, as most cases are self-limiting though painful; antivenom reserved for severe systemic symptoms (significant muscle cramping, autonomic instability) given anaphylaxis risk with antivenom itself; monitor for latrodectism (generalised muscle pain, cramping, autonomic symptoms) evolution over hours; benzodiazepines can help muscle spasm/pain in the interim.
- Jellyfish sting (severe): Vinegar irrigation (for box jellyfish species) or hot water immersion (for many other species) first-line depending on the likely species, as treatment is species-specific and the wrong measure can worsen envenomation; antivenom for severe box jellyfish envenomation where available; monitor for systemic toxicity (cardiovascular, respiratory) in severe stings, particularly with Chironex/Irukandji syndrome; analgesia and wound care as supportive measures.
- Methanol poisoning: Fomepizole (or ethanol if fomepizole unavailable) first-line to block alcohol dehydrogenase and prevent toxic metabolite formation; folinic acid as an adjunct to enhance formate metabolism; haemodialysis for severe poisoning (significant acidosis, visual symptoms, high levels, renal failure); monitor anion/osmolar gap, visual symptoms (a hallmark of methanol toxicity), and acid-base status closely.
- Ethylene glycol poisoning: Fomepizole (or ethanol if unavailable) first-line to block alcohol dehydrogenase; IV calcium and correction of severe hypocalcaemia (from calcium oxalate crystal formation) as needed; haemodialysis for severe poisoning (significant acidosis, renal impairment, high levels); monitor renal function closely given risk of acute kidney injury from oxalate crystal deposition, and anion/osmolar gap trend.
- Iron overdose (acute): IV desferrioxamine chelation first-line for significant systemic toxicity (based on clinical severity and/or serum iron level); whole bowel irrigation for large ingestions with radiopaque tablets visible on abdominal X-ray; monitor serum iron level, acid-base status, and for the biphasic course (initial GI toxicity, apparent recovery, then delayed shock/hepatic failure) which can mislead if surveillance is stopped too early.
- Organophosphate poisoning (severe): IV atropine titrated to secretions (not heart rate) first-line, given in escalating doses until secretions dry; add pralidoxime early to reactivate acetylcholinesterase before ageing occurs; decontamination (remove clothing, wash skin) protects staff and patient; monitor for the intermediate syndrome (delayed respiratory muscle weakness) which can occur after apparent initial recovery, requiring close observation and ventilatory support readiness.
- Lithium toxicity: IV fluids first-line to promote renal excretion (avoiding NSAIDs/ACE-I/diuretics which impair lithium clearance and are common precipitants); haemodialysis for severe toxicity (significant neurological symptoms, very high levels, renal failure, or inability to tolerate fluids); monitor lithium levels serially, as levels can continue rising after ingestion (chronic toxicity) or with slow-release preparations; distinguish acute-on-chronic toxicity, which correlates less well with level and more with clinical severity.
- Serotonin syndrome: Immediate discontinuation of serotonergic agents first-line, alongside supportive care and benzodiazepines for agitation/muscle rigidity; cyproheptadine (serotonin antagonist) for moderate-severe cases; monitor for hyperthermia and autonomic instability, with active cooling for significant hyperthermia; distinguish from neuroleptic malignant syndrome by the drug history and clinical pattern (hyperreflexia/clonus favouring serotonin syndrome), as management differs.
- Neuroleptic malignant syndrome (severe): Immediate discontinuation of the causative antipsychotic (or dopaminergic withdrawal management if precipitated by dopamine agonist cessation) first-line, alongside supportive cooling and hydration; dantrolene or bromocriptine for severe cases; monitor creatine kinase, renal function (rhabdomyolysis-related AKI), and temperature closely; benzodiazepines help agitation; this typically evolves over days, distinguishing it from the more rapid-onset serotonin syndrome.
- Acute mesenteric ischaemia (post-cardiac surgery): Urgent CT angiography and surgical/endovascular revascularisation with resection of non-viable bowel first-line, given very high mortality if diagnosis is delayed in this high-risk post-operative population; maintain a high index of suspicion given atypical/subtle presentation in sedated, post-operative patients; monitor lactate and abdominal examination closely in at-risk patients (low cardiac output, vasopressor use, prolonged bypass); broad-spectrum antibiotics given bacterial translocation risk.
Palliative Care & Pain Medicine
- Cancer pain (moderate-severe): WHO analgesic ladder with regular (not solely as-needed) opioid titration and adjuvant agents (neuropathic agents, corticosteroids for nerve compression/raised intracranial pressure, bisphosphonates for bone pain) is first-line; escalate opioid dose steadily against response rather than under-dosing out of unfounded dependence concerns; monitor pain scores and side effects (sedation, constipation) regularly; co-prescribe a laxative routinely and reassess the underlying cause if pain pattern changes.
- Breakthrough pain: Immediate-release opioid rescue dosing (typically 1/6th to 1/10th of the total daily background dose) alongside the regular background analgesic regimen is first-line; escalate the background dose if breakthrough episodes are frequent (more than 3-4 per day) rather than relying solely on rescue doses; monitor timing and triggers of breakthrough pain (incident vs spontaneous) to guide whether pre-emptive dosing before a triggering activity is more appropriate.
- Opioid-induced constipation: Prophylactic stimulant laxative (e.g. senna) co-prescribed with opioid therapy from initiation is first-line, as constipation does not develop tolerance the way other opioid side effects do; escalate to combination laxatives or a peripherally acting mu-opioid receptor antagonist for refractory cases; monitor bowel habit proactively rather than waiting for the patient to report symptoms, as under-reporting is common.
- Terminal dyspnoea: Low-dose opioids (titrated for symptom relief rather than respiratory depression) are first-line, with benzodiazepines added where anxiety is a significant contributor, alongside non-pharmacological measures (fan directed at the face, positioning, room ventilation); monitor comfort rather than respiratory rate or oxygen saturation as the primary target in the terminal phase; reassure family that opioid use for comfort in this setting does not hasten death when appropriately titrated.
- Malignant bowel obstruction (inoperable): Antisecretory (octreotide/hyoscine butylbromide) and antiemetic medication with analgesia is first-line for symptom control where surgery is not appropriate; escalate to a venting gastrostomy for refractory vomiting significantly affecting quality of life; monitor symptom burden and titrate medications for comfort rather than pursuing bowel function restoration, which is often not achievable in this setting; involve the patient and family in goals-of-care discussions given the prognostic implications.
- Terminal agitation: Anxiolytic/sedative medication (benzodiazepines, or antipsychotics if a delirium component is prominent) titrated for comfort is first-line, with attention to reversible causes (urinary retention, pain, constipation, medication effects) sought and addressed where feasible; monitor comfort and family understanding closely, as terminal agitation is distressing for those present; explain the approach and likely trajectory to family to support their coping.
- Neuropathic pain: Gabapentinoids (gabapentin/pregabalin), tricyclic antidepressants, or SNRIs (duloxetine) are first-line agents, chosen based on comorbidities and side-effect tolerability; escalate to combination therapy or specialist pain referral for refractory pain; monitor for sedation and, in older patients, falls risk with gabapentinoids/tricyclics; allow an adequate trial period (several weeks) before concluding an agent has failed, as response is often gradual.
- Complex regional pain syndrome: Multidisciplinary physiotherapy and pain management (with emphasis on early, graded mobilisation and desensitisation) is first-line; neuropathic agents and nerve blocks (sympathetic blocks) as adjuncts for refractory pain; monitor functional progress as the primary outcome measure rather than pain scores alone, as early mobilisation despite pain improves long-term function; early diagnosis and treatment initiation improve prognosis significantly.
- Chronic non-cancer pain: Multimodal, function-focused management (physiotherapy, psychological therapy, non-opioid analgesics) minimising long-term opioid reliance is first-line, given limited long-term opioid efficacy evidence and dependence risk in this setting; monitor functional outcomes rather than pain scores alone as the primary treatment goal; if opioids are used, set clear functional goals and review regularly, tapering if benefit is not demonstrated.
- Malignant spinal cord compression (palliative setting): Urgent high-dose corticosteroids and radiotherapy is first-line, started promptly on clinical suspicion given the time-critical nature of neurological outcome; surgical decompression for select patients with good performance status and a single level of compression, particularly with spinal instability; monitor neurological status (motor/sensory level, bladder/bowel function) closely, as this is an oncological emergency requiring same-day assessment and treatment initiation.
- Cancer-related fatigue: Exercise therapy where tolerated (often counterintuitive to patients but evidence-supported) is first-line, alongside treatment of contributing factors (anaemia, hypothyroidism, sleep disturbance, depression, medication side effects); monitor for reversible contributors that are frequently overlooked as "just part of cancer"; psychostimulants have limited evidence and are reserved for specific refractory cases under specialist guidance.
- Cachexia (cancer-related): Nutritional support and treatment of reversible contributing factors (pain limiting intake, nausea, mucositis, depression) is first-line; limited role for appetite stimulants (megestrol, corticosteroids for short-term use), which do not reverse the underlying catabolic process; monitor weight and functional status while setting realistic goals with the patient/family, as cachexia in advanced disease often does not fully reverse with nutritional intervention alone.
- End-of-life secretions (death rattle): Anticholinergic medication (hyoscine hydrobromide/glycopyrronium) and repositioning (lateral position to aid drainage) is first-line; reassurance for family that this is a common, generally non-distressing (to the patient) part of the dying process, as it is often more distressing to observers than the patient; monitor comfort rather than aiming to eliminate the sound entirely, which is often not fully achievable.
- Opioid-induced neurotoxicity: Opioid rotation (switching to an alternative opioid at a reduced equianalgesic dose) or dose reduction with adequate hydration is first-line for myoclonus, hyperalgesia, or confusion attributed to opioid accumulation; monitor renal function, as neurotoxicity is more common with renal impairment due to accumulation of active metabolites; distinguish from disease progression or other causes of confusion before attributing symptoms solely to opioids.
- Bone pain (metastatic): Analgesia per the WHO ladder plus palliative radiotherapy (often single-fraction) for localised pain is first-line; escalate to bisphosphonates/denosumab to reduce skeletal-related events and, for widespread bone metastases, consider radioisotope therapy; monitor for pathological fracture risk (Mirels' score) and refer for prophylactic orthopaedic fixation if impending fracture is identified.
- Existential/spiritual distress (palliative setting): Multidisciplinary psychosocial and spiritual care support alongside symptom management is first-line, recognising that physical symptom control alone does not address this dimension of suffering; monitor for coexisting depression or anxiety, which can present similarly but may benefit from additional targeted treatment; involve chaplaincy/spiritual care and psychology/counselling services proactively rather than only on request, as patients may not raise this distress unprompted.
Forensic & Legal Medicine
- Suspected physical child abuse: Safeguarding referral is first-line and mandatory once suspicion arises, alongside thorough, contemporaneous documentation of injuries (photography, body maps, injury dating where possible) and a multidisciplinary child protection assessment; escalate to admission for safety and further investigation (skeletal survey, ophthalmological exam) if abuse is significantly suspected; monitor the child's ongoing safety and involve child protection services regardless of parental reassurance, as the duty to report overrides diagnostic certainty.
- Sexual assault (recent): Forensic examination with informed consent by a trained examiner is first-line, ideally within the recommended forensic window, alongside prophylaxis for sexually transmitted infections and emergency contraception where relevant; psychological support and referral to specialist services is essential alongside the medical/forensic assessment; monitor for delayed disclosure of injuries and psychological sequelae, and ensure the patient retains control over reporting to police, which should not be a precondition for receiving care.
- Suspected domestic violence: Safety assessment (including a structured risk assessment tool) is first-line, alongside documentation of injuries and referral to support/legal services; escalate to safety planning and, where children are involved, child safeguarding assessment; monitor for escalating severity and recognise that leaving an abusive relationship carries elevated short-term risk, so safety planning should be individualised rather than assuming departure is always the safest immediate step.
- Death in custody (unexplained): Mandatory medico-legal autopsy and full, independent documentation for inquest is first-line, given the heightened scrutiny and public interest in custodial deaths; escalate to involvement of an independent forensic pathologist rather than the treating institution's own staff to preserve impartiality; monitor chain-of-custody of the body and all evidence meticulously, as procedural integrity is essential for legal proceedings.
- Suspected poisoning (forensic): Preservation of samples (blood, urine, gastric contents) for toxicological analysis alongside clinical management is first-line, taken before treatment where feasible without delaying life-saving care; escalate to police/forensic toxicology involvement where criminal intent is suspected; monitor and clearly document the clinical course and sample chain-of-custody, as toxicological findings may later be scrutinised in legal proceedings.
- Fitness to stand trial assessment: Structured psychiatric/psychological evaluation against the relevant legal criteria (understanding of charges, ability to instruct counsel, understanding of court proceedings) is first-line; escalate to a second independent opinion where the assessment is contested or borderline; monitor for fluctuating capacity (e.g. in psychosis or intoxication states) that may require reassessment closer to the trial date rather than relying on a single point-in-time evaluation.
- Elder abuse (suspected): Safeguarding assessment, thorough documentation, and referral to adult protective services is first-line; escalate to removal from the abusive environment or involvement of legal/guardianship services where the individual lacks capacity to protect themselves; monitor for financial as well as physical/psychological abuse, which frequently co-occurs and is often under-recognised; involve the individual in decision-making to the extent their capacity allows, respecting autonomy alongside protection.
- Non-accidental injury in infants: Skeletal survey, multidisciplinary safeguarding review, and referral to child protection services is first-line once suspicion arises, given infants cannot self-report and injuries may otherwise go unrecognised; escalate to admission for safety pending assessment; monitor for patterns inconsistent with the reported mechanism (e.g. injuries at different healing stages, injury patterns atypical for developmental stage) which should heighten rather than resolve suspicion.
- Custodial death investigation: Independent forensic autopsy with full, meticulous chain-of-custody documentation is first-line, mirroring the approach to death in custody given overlapping legal and procedural requirements; escalate to external/independent review bodies where local conflict of interest exists; monitor and preserve all relevant records (medical, custody logs, CCTV where available) promptly before they can be altered or lost.
- Sexual assault of a minor: Immediate safeguarding referral is first-line and takes priority, alongside forensic examination by specialists trained in paediatric forensic assessment and psychological support tailored to the child's developmental stage; escalate to urgent multidisciplinary child protection team involvement; monitor for ongoing risk to the child (returning to an unsafe environment) and ensure age-appropriate, non-leading interview techniques are used throughout to preserve both welfare and evidential integrity.
- Human trafficking (suspected victim): Confidential safeguarding assessment conducted separately from any accompanying person (who may be the trafficker) is first-line, followed by referral to specialist support services; escalate to law enforcement involvement only with the victim's informed understanding, as coercive control often makes victims fearful of authorities; monitor for indicators of coercion (accompanying "helper" answering for the patient, inconsistent stories, signs of control) and prioritise the individual's immediate safety and trust-building over information extraction.
Community Medicine & Public Health
- Outbreak of acute diarrhoeal disease: Case isolation and oral rehydration at the point of care is first-line for individual management, alongside water source investigation and chlorination to control the outbreak; escalate to broader public health response (case reporting, community education) if a common source is identified; monitor case numbers and geographic spread to detect ongoing transmission, and prioritise identifying and closing the source (contaminated water, food) over treating cases individually.
- Suspected foodborne illness cluster: Epidemiological investigation (case interviews, exposure mapping) and source tracing is first-line, alongside mandatory public health notification; escalate to product recall or premises closure if a specific food source is confirmed; monitor for additional cases during the investigation period, as clusters can grow before the source is identified and controlled.
- Vaccine-preventable disease case (e.g. measles): Case isolation and contact tracing is first-line, alongside outbreak-response immunisation of susceptible contacts (within the appropriate window post-exposure); escalate to broader community vaccination campaigns if secondary transmission is occurring; monitor vaccination coverage in the affected area and identify under-immunised pockets that allowed transmission, addressing access or hesitancy barriers as part of the response.
- Malnutrition in under-five children: Community-based management of acute malnutrition with therapeutic feeding (ready-to-use therapeutic food for uncomplicated severe cases) and growth monitoring is first-line; escalate to inpatient stabilisation for complicated severe malnutrition with medical complications (oedema, infection, severe wasting with appetite loss); monitor weight-for-height/MUAC serially and screen for and treat underlying infections, as malnutrition and infection compound each other.
- Iodine deficiency disorder (endemic goitre): Universal salt iodisation is first-line population-level prevention, with targeted supplementation (iodised oil) in severely affected regions where salt iodisation coverage is incomplete; monitor urinary iodine levels at a population level to assess programme adequacy; screen pregnant women specifically given the severe neurodevelopmental consequences of maternal iodine deficiency on the fetus.
- Vitamin A deficiency (xerophthalmia): High-dose vitamin A supplementation is first-line treatment for at-risk/affected children, alongside dietary diversification programmes for sustainable prevention; escalate to urgent treatment for corneal involvement (keratomalacia) given risk of irreversible blindness; monitor programme coverage in supplementation campaigns and screen for concurrent measles/diarrhoeal disease, which both deplete and are worsened by vitamin A deficiency.
- Zoonotic disease exposure (e.g. animal bite): Wound care (thorough washing) and rabies risk assessment is first-line, with post-exposure prophylaxis (vaccine, and immunoglobulin for high-risk exposures) given promptly as indicated; escalate to full post-exposure regimen without delay if the biting animal cannot be observed/tested, given the near-uniform fatality of untreated rabies; monitor the biting animal where possible (10-day observation for dogs/cats) to potentially avoid unnecessary immunoglobulin, but never delay vaccination while awaiting this.
- Occupational lead poisoning: Removal from exposure is first-line and essential, as continued exposure will undermine any treatment; chelation therapy for significant toxicity (based on blood lead level and symptoms) as an adjunct; workplace safety review and monitoring of coworkers for exposure; monitor blood lead levels serially during and after treatment, and address the exposure source at a systems level rather than treating affected individuals in isolation.
- Silicosis (occupational): Removal from further silica exposure is first-line, as there is no curative therapy once fibrosis is established; supportive respiratory care (bronchodilators, pulmonary rehabilitation, oxygen if hypoxic) for symptom management; monitor for disease progression and increased tuberculosis risk (silicotuberculosis), screening periodically; workplace dust control and respiratory protection are the key preventive measures for at-risk workers.
- Antenatal care for a low-risk pregnancy: Scheduled screening visits (per recommended antenatal visit schedule), supplementation (iron/folate, calcium where indicated), and health education is first-line; escalate to increased surveillance if risk factors emerge during pregnancy (hypertension, growth concerns, gestational diabetes); monitor for the development of risk factors at each visit rather than assuming continued low-risk status throughout pregnancy.
- Tuberculosis contact tracing: Screening of close contacts (symptom screen, chest imaging/testing) is first-line once an index case is identified, with preventive therapy offered to those found to have latent infection, particularly high-risk contacts (children, HIV-positive, immunosuppressed); escalate to wider community screening if transmission beyond the household is suspected; monitor contacts who decline or cannot access preventive therapy for symptom development over the following months.
- Water-borne disease prevention (community): Safe water supply interventions (protected sources, household treatment) alongside chlorination and hygiene education is first-line; escalate to emergency water trucking/treatment during outbreaks or disaster settings where the usual supply is compromised; monitor water quality testing regularly and disease surveillance data to evaluate intervention effectiveness.
- Vector control for dengue/malaria (community): Source reduction (eliminating breeding sites) and larvicidal measures are first-line, alongside community education campaigns to sustain behaviour change; escalate to indoor residual spraying or insecticide-treated nets for malaria in high-transmission settings; monitor vector density and disease incidence to guide the intensity and targeting of control measures, adapting to insecticide resistance patterns where relevant.
- School health screening programme: Structured periodic screening for growth, vision, hearing, and immunisation status is first-line, with referral pathways established for identified abnormalities; monitor screening coverage and follow-up completion rates, as identifying a problem without ensuring referral completion limits programme impact; integrate with broader school health education (nutrition, hygiene) for maximum benefit.
- Non-communicable disease screening (community): Population-based screening for hypertension, diabetes, and obesity with clear referral pathways to confirmatory testing and management is first-line; monitor screening uptake, particularly in underserved populations where non-communicable disease burden is often highest but access to screening lowest; ensure referral pathways are actually resourced to manage the volume of positive screens identified, avoiding screening without capacity to treat.
- Occupational noise-induced hearing loss: Workplace hearing protection programmes (engineering controls, personal protective equipment) are first-line prevention, alongside periodic audiometric screening to detect early hearing loss before it becomes disabling; monitor audiometric trends over time in exposed workers, and remove/reassign workers with significant threshold shifts from further high-noise exposure where feasible.
- Snakebite prevention (rural community): Community education (on avoidance behaviours, appropriate first aid) and appropriate footwear promotion is first-line prevention; ensured antivenom access at accessible health facilities is essential given the time-critical nature of envenomation treatment; monitor antivenom stock and cold-chain maintenance at peripheral facilities, as stockouts in high-incidence rural areas are a major driver of preventable mortality.
Genetics, Metabolic & Congenital Disorders
- Down syndrome: Multidisciplinary surveillance for associated cardiac, endocrine (thyroid), haematological, and developmental issues is first-line, as there is no curative treatment for the underlying trisomy; escalate to targeted treatment of specific complications as they arise (e.g. cardiac surgery for AV septal defect); monitor growth using Down-syndrome-specific charts, hearing/vision periodically, and thyroid function annually, given the high prevalence of treatable comorbidities that affect development.
- Phenylketonuria: Lifelong dietary phenylalanine restriction, detected via newborn screening and started as early as possible, is first-line, as delayed treatment risks irreversible intellectual disability; escalate to sapropterin (for responsive genotypes) or pegvaliase as adjunct/alternative therapy in eligible patients with poor dietary control; monitor phenylalanine levels regularly (more frequently in infancy and pregnancy) and reinforce dietary adherence, particularly around puberty when adherence often lapses.
- Galactosaemia: Immediate lifelong exclusion of galactose/lactose from the diet is first-line, started as soon as diagnosis is suspected (often before genetic confirmation) given risk of rapid deterioration (sepsis, liver failure) with continued exposure; monitor growth, liver function, and developmental progress, as some long-term complications (cognitive, ovarian insufficiency) may occur despite early and strict dietary treatment.
- Maple syrup urine disease: Dietary restriction of branched-chain amino acids is first-line long-term management, with acute management of metabolic crises (IV glucose/insulin, temporary protein restriction, escalation to dialysis for severe decompensation) during intercurrent illness; monitor plasma amino acid levels regularly and educate families on sick-day management, as intercurrent illness is the most common trigger for life-threatening metabolic crisis.
- Glycogen storage disease (type I): Frequent feeding/cornstarch therapy to maintain euglycaemia is first-line, with overnight nasogastric feeding or extended-release cornstarch used to prevent nocturnal hypoglycaemia; monitor growth, lactate, uric acid, and lipid profile regularly, and screen for long-term complications (hepatic adenomas, renal disease) with periodic imaging; strict avoidance of fasting is essential even during minor illness.
- Wilson's disease: Copper chelation therapy (penicillamine or trientine) is first-line for symptomatic disease, with zinc used for maintenance therapy or in presymptomatic/pregnant patients given its lower side-effect profile; dietary copper restriction as an adjunct; monitor liver function, 24-hour urinary copper excretion, and neurological status regularly, as treatment is lifelong and abrupt discontinuation risks rapid decompensation; screen siblings given the autosomal recessive inheritance pattern.
- Haemochromatosis: Regular therapeutic phlebotomy to reduce iron overload is first-line, with an intensive induction phase followed by maintenance phlebotomy guided by ferritin levels; escalate to iron chelation therapy for patients unable to tolerate phlebotomy (e.g. anaemia, poor venous access); monitor ferritin, transferrin saturation, and screen for end-organ damage (liver, cardiac, endocrine) at diagnosis and periodically; screen first-degree relatives given the genetic basis.
- Marfan syndrome: Beta-blocker or ARB therapy to slow aortic root dilation is first-line, alongside surveillance echocardiography (and periodic broader aortic imaging) and elective aortic surgery when the aortic diameter or growth rate crosses established thresholds; monitor aortic dimensions serially, restrict high-intensity/contact sports given dissection risk, and screen for lens dislocation and skeletal features as part of comprehensive multisystem surveillance.
- Neurofibromatosis type 1: Surveillance for tumour development (optic pathway glioma, plexiform neurofibroma, malignant peripheral nerve sheath tumour) is first-line, with management of complications as they arise (surgery for symptomatic tumours, MEK inhibitor therapy for inoperable symptomatic plexiform neurofibromas); monitor growth, blood pressure (renal artery stenosis, phaeochromocytoma risk), vision, and skeletal development (scoliosis) at regular intervals given the multisystem nature of the condition.
- Tuberous sclerosis complex: mTOR inhibitor therapy (everolimus) for significant tumour burden (subependymal giant cell astrocytoma, renal angiomyolipoma, refractory epilepsy) is first-line where surgery is not appropriate; seizure management (including vigabatrin as first-line for infantile spasms in this condition specifically) and developmental support alongside; monitor with periodic brain and renal imaging, and screen for autism spectrum features and developmental delay proactively.
- Fragile X syndrome: Supportive developmental, educational, and behavioural intervention is first-line, as there is no curative therapy; target specific behavioural symptoms (hyperactivity, anxiety) pharmacologically where significantly impairing; monitor developmental progress and screen for common comorbidities (ADHD, autism spectrum features, seizures); genetic counselling for the family regarding X-linked inheritance and premutation carrier risks (including premature ovarian insufficiency and tremor-ataxia syndrome in carriers) is important.
- Congenital adrenal hyperplasia: Lifelong glucocorticoid replacement (and mineralocorticoid replacement if salt-wasting) is first-line, with stress dosing during illness/surgery to prevent adrenal crisis; monitor growth, bone age, and biochemical markers (17-hydroxyprogesterone, electrolytes) regularly to balance adequate androgen suppression against growth suppression from over-treatment; educate families thoroughly on emergency stress-dose administration and provide a steroid emergency card/injection kit.
- Cystic fibrosis (CFTR modulator eligible): CFTR modulator therapy (e.g. elexacaftor-tezacaftor-ivacaftor) for eligible mutations is first-line where genotype allows, alongside continued airway clearance and pancreatic enzyme replacement as needed; monitor lung function, liver function (modulators can affect hepatic enzymes), and growth on treatment; modulator therapy has transformed prognosis in eligible patients but does not eliminate the need for ongoing multidisciplinary CF care.
- Sickle cell disease (chronic management): Hydroxyurea to reduce vaso-occlusive crisis frequency is first-line for most patients with recurrent crises, with transfusion therapy (simple or exchange) for select complications (stroke prevention, acute chest syndrome, pre-operative optimisation); monitor for hydroxyurea-related cytopenias and long-term organ damage (renal, pulmonary, retinal) with periodic screening; penicillin prophylaxis and pneumococcal vaccination in childhood reduce infection risk from functional asplenia.
- Gaucher disease: Enzyme replacement therapy (imiglucerase) or substrate reduction therapy (for those unable to tolerate/access enzyme replacement) is first-line for type 1 disease; monitor haematological parameters, organomegaly, and bone involvement (via imaging) to assess treatment response; type 2/3 neuronopathic disease has more limited treatment options given poor CNS penetration of current enzyme replacement therapies.
- Pompe disease: Enzyme replacement therapy (alglucosidase alfa) is first-line, with earlier initiation in infantile-onset disease strongly associated with better outcomes given rapid cardiac and respiratory deterioration otherwise; monitor cardiac function, respiratory status, and motor development closely, particularly in the infantile form; screen for antibody development against the enzyme, which can reduce treatment efficacy over time.
- Mucopolysaccharidosis (type I): Enzyme replacement therapy is first-line for attenuated disease, with haematopoietic stem cell transplant considered for severe early-onset (Hurler) disease, ideally performed early before significant neurological involvement develops; monitor growth, joint mobility, cardiac and respiratory function, and neurodevelopment; enzyme replacement does not cross the blood-brain barrier, limiting its effect on neurological manifestations in severe disease.
- Osteogenesis imperfecta: Bisphosphonate therapy to increase bone density and reduce fracture rate is first-line for moderate-severe disease; supportive orthopaedic management (fracture care, rodding for recurrent long bone fractures) and physiotherapy alongside; monitor bone density, growth, and hearing (progressive hearing loss is common); genetic counselling given variable inheritance patterns across the different types.
- Achondroplasia: Symptomatic management of complications (spinal stenosis, sleep apnoea, recurrent otitis media) is first-line, as this is the mainstay of care; growth hormone therapy has limited height benefit and is not routinely used, while limb-lengthening or CNP-analogue therapy (vosoritide, where available) are options in select cases; monitor for foramen magnum stenosis in infancy (a cause of sudden death if severe) and spinal stenosis in adulthood proactively with periodic assessment.
- Ehlers-Danlos syndrome: Supportive management (physiotherapy for joint stabilisation, joint protection strategies, pain management) is first-line, as there is no curative therapy; monitor for vascular complications specifically in the vascular subtype (arterial/organ rupture risk), which requires closer surveillance and activity modification than the more common hypermobile subtype; screen for cardiac valve involvement and counsel on pregnancy risks in the vascular subtype given significant maternal risk.
- Turner syndrome: Growth hormone therapy in childhood to optimise final height is first-line, with oestrogen replacement introduced from the expected age of puberty to induce secondary sexual characteristics and protect bone health; monitor cardiac (coarctation, bicuspid aortic valve), renal, thyroid, and hearing status regularly given multisystem associations; fertility counselling is important given the high prevalence of ovarian insufficiency.
- Klinefelter syndrome: Testosterone replacement therapy from the expected age of puberty is first-line as needed for hypogonadism, supporting secondary sexual characteristic development and bone/muscle health; monitor for learning difficulties, gynaecomastia, and metabolic syndrome features, which are more common in this condition; discuss fertility options early, as most affected men have impaired spermatogenesis though assisted reproduction may be possible.
- Prader-Willi syndrome: Growth hormone therapy is first-line, improving height, body composition, and muscle tone, alongside structured dietary management (calorie restriction, food security measures) for hyperphagia, which is the dominant long-term management challenge; monitor growth, weight, and behavioural/psychiatric symptoms (which are common and can be severe) closely; screen for sleep apnoea and scoliosis, and involve a multidisciplinary team given the complexity of lifelong management.
- Angelman syndrome: Supportive developmental and seizure management is first-line, as there is no curative therapy for the underlying genetic cause; monitor seizure control closely given epilepsy is common and can be difficult to control; involve multidisciplinary support (speech/communication aids given typically absent or limited verbal speech, physiotherapy for gait abnormalities, behavioural support) tailored to the individual's needs and communication profile.
Radiology & Interventional Management
- Acute ischaemic stroke (large vessel occlusion): Endovascular mechanical thrombectomy within the eligible time window (extended further with favourable perfusion imaging) is first-line, alongside IV thrombolysis where not contraindicated and within its own separate time window; monitor neurological status and repeat imaging for haemorrhagic transformation post-procedure; time from symptom onset to reperfusion is the dominant driver of outcome, making rapid triage and transfer to a thrombectomy-capable centre essential.
- Symptomatic uterine fibroids (fertility-sparing): Uterine artery embolisation is first-line as a minimally invasive alternative to surgery for women wishing to avoid myomectomy/hysterectomy or preserve the uterus; monitor for post-embolisation syndrome (pain, fever, malaise in the days following the procedure, usually self-limiting) and for fibroid expulsion; counsel that fertility outcomes after embolisation are less well-established than after myomectomy, and discuss this alongside surgical alternatives for those specifically pursuing pregnancy.
- Hepatocellular carcinoma (unresectable): Transarterial chemoembolisation or radiofrequency/microwave ablation depending on tumour characteristics (size, number, location) is first-line for unresectable disease confined to the liver with preserved liver function; escalate to systemic therapy for more advanced or refractory disease; monitor liver function and imaging response, and screen for post-embolisation syndrome; treatment choice is guided by staging systems that integrate tumour burden with underlying liver function.
- Biliary obstruction (malignant, unresectable): Percutaneous transhepatic or endoscopic biliary stenting for decompression is first-line for symptomatic relief of jaundice/cholangitis where surgical resection is not feasible; monitor for stent occlusion/cholangitis over time, with stent exchange or upsizing as needed; choice between percutaneous and endoscopic approach depends on the level of obstruction and local expertise/anatomy.
- Abscess (deep-seated, e.g. hepatic/renal): Image-guided percutaneous drainage with concurrent targeted antibiotics is first-line for most deep-seated abscesses amenable to a safe drainage route; escalate to surgical drainage if percutaneous access is unsafe, the abscess is multiloculated and not responding, or there is associated bowel perforation requiring source control; monitor clinical response, inflammatory markers, and repeat imaging to confirm resolution before catheter removal.
- Peripheral arterial occlusive disease (critical limb ischaemia): Endovascular angioplasty/stenting is first-line for suitable lesion patterns given lower morbidity than surgery; surgical bypass for extensive disease not amenable to endovascular repair or where durability requirements favour surgery; monitor limb perfusion, wound healing, and patency with surveillance imaging; time to revascularisation is critical in critical limb ischaemia given amputation risk with delay.
- Pulmonary embolism (intermediate-high risk): Catheter-directed thrombolysis is an option for select patients with a contraindication to (or failure of) systemic thrombolysis, alongside standard anticoagulation; escalate to surgical embolectomy or ECMO for massive PE with haemodynamic collapse refractory to other measures; monitor haemodynamic status, right heart strain on echocardiography, and bleeding risk closely given the competing risks of thrombolytic therapy.
- Varicocele (image-guided): Percutaneous embolisation is first-line as a minimally invasive alternative to surgical ligation, particularly for symptomatic varicocele or those affecting fertility; monitor semen parameters where fertility is the indication, and for varicocele recurrence post-embolisation; both embolisation and surgical approaches have comparable efficacy, with choice often guided by local expertise and patient preference.
- Deep vein thrombosis (iliofemoral, limb-threatening): Catheter-directed thrombolysis is first-line to reduce post-thrombotic syndrome risk in select patients with extensive iliofemoral DVT and low bleeding risk, alongside standard anticoagulation; monitor for bleeding complications during thrombolysis and for adequate anticoagulation continuation afterward; phlegmasia cerulea dolens with limb-threatening ischaemia warrants urgent intervention given risk of venous gangrene.
- Gastrointestinal bleeding (refractory to endoscopy): Transarterial embolisation of the bleeding vessel is first-line once endoscopic haemostasis has failed or is not feasible; escalate to surgery if embolisation fails to control bleeding or is not technically possible given vascular anatomy; monitor haemodynamic status and haemoglobin closely, and identify the bleeding source with CT angiography or tagged red cell scan pre-procedure where the source is unclear.
- Nephrostomy for obstructed infected kidney: Percutaneous nephrostomy placement for urgent decompression is first-line in an obstructed, infected kidney (infected hydronephrosis), given the risk of urosepsis with delay; concurrent IV antibiotics alongside drainage; monitor for improvement in sepsis markers and renal function post-drainage, and plan definitive treatment of the underlying obstruction (stone removal, stricture management) once the acute infection is controlled.
- Portal hypertension (refractory variceal bleeding/ascites): Transjugular intrahepatic portosystemic shunt (TIPS) is first-line for variceal bleeding refractory to endoscopic and pharmacological therapy, or for refractory ascites requiring frequent large-volume paracentesis; monitor for hepatic encephalopathy post-TIPS, a common complication given the portosystemic shunting; assess liver function and cardiac status pre-procedure, as TIPS is contraindicated in significant hepatic or cardiac decompensation.
- Renal artery stenosis (fibromuscular dysplasia): Percutaneous transluminal angioplasty is first-line, often curative in this population (younger patients with fibromuscular disease, distinct from atherosclerotic renal artery stenosis where medical therapy is usually preferred); monitor blood pressure response and renal function post-procedure; stenting is generally reserved for angioplasty failure or dissection given good angioplasty-alone outcomes in fibromuscular disease.
- Bronchial artery bleeding (haemoptysis): Bronchial artery embolisation is first-line for massive or recurrent haemoptysis once the source is localised (bronchoscopy/CT angiography); monitor for recurrent bleeding, which can occur from collateral vessels not embolised initially or from the original vessel if incompletely occluded; identify and treat the underlying cause (bronchiectasis, tuberculosis, malignancy) alongside acute haemorrhage control.
- Pelvic congestion syndrome: Ovarian/pelvic vein embolisation is first-line for confirmed symptomatic disease after excluding other causes of chronic pelvic pain; monitor symptom response over weeks to months, as improvement is often gradual; recurrence or incomplete symptom relief may prompt evaluation for additional incompetent veins requiring further embolisation.
- Splenic artery aneurysm: Endovascular coil embolisation is first-line for aneurysms above the size threshold for intervention (or smaller aneurysms in pregnancy/women of childbearing age given rupture risk in pregnancy) rather than open surgical repair given lower morbidity; monitor for post-embolisation splenic infarction (usually well-tolerated if partial) and confirm aneurysm exclusion with follow-up imaging; asymptomatic small aneurysms below threshold are typically monitored with serial imaging rather than treated.