iDr Abhijit Mandal, MBBS(Cal), DNB(Family Medicine),SMO
DNB Family Medicine : Tactical plan for clearing practical
It’s an absolute high standard postgraduate examination.You have to study a lot but don’t go in
deep.Understanding the basics is key to success.Knowledge in breadth is more required than in
depth. Try to study all the topics as mentioned below.
It’s one day examination from 0800hrs to 1630 hrs(time may vary from centre to centre)
There five broad divisions in practicals
1.Medicine and allied
2.Surgery
3.Pediatrics
4.Community Medicine
5.Family Medicine
Marks distribution as follows:
A.Medicine and allied: Total 100 marks
I. Long case: one
total marks :45 marks
II Short case: one
total marks:30 marks
III. Viva: a.Lab reports,x-rays,ECGs one question from each topic total 10 marks
b.Drugs: one commonly used drug
05 marks
c.Therapeutic and diagnostic procedure:
10 marks
B.Surgery/Obs& Gynae /ENT/EYE/ORTHO: Total marks:25
I.Short case:one case
C.Pediatrics: Total 75 marks
I.Two Short cases:
II.Viva: recent advances,neonatology,instruments,preventive pediatrics
25 marks
40 marks
35 marks
D.Community Medicine: Total marks:50
a.National Health Policy:
10 marks
b.Health programmes:
15 Marks
c. Health indicators,health legislation,community health delivery services:10 marks
d.Vital statistics, promotive & preventive medicine:
15 marks
E.Family Medicine: Total marks:50
a.Morbidity pattern,Record keeping:
b. Managementof cases in family set up:
c.Emergencies:
d. Medical Ethics,referrals,CME etc :
10 marks
15 marks
15 marks
10 marks
Things to carry: Admit card,white coat,basic examination tools and above all self confidence
GENERAL GUIDELINES FOR CASE PRESENTATION AND
DISCUSSION:
MEDICINE
Cerebro-vascular disease
History - Detailed history relating to the event onset, progress, neurological deficit(s);
Assessment of risk factors for CVA; If young patient, to evaluate for ‘Stroke in young’;
Medication/Treatment history
Clinical examination - Vital Signs-pulse, BP, RR, Temp., Eval. Of carotids; Detailed
Neurological exam including (Cranial N Palsies – Speech;Pupillary Signs;Motor System
Examination); Exam of Heart/CNS; To evaluate for causes of stroke in young;Should be able to
identify the Vascular Territory involved Fundus Exam.
Investigations-All investigations but specifically-ECG;NCCT(Head);Role of
CECT(Head);MRI(Brain);Carotid Doppler; Role of ECHO.
Differential diagnosis-CVA ( Haemorrhagic,Thrombotic); In young patients (Aneurysm,AVM);
Other Causes (Vasculitis;SOL; Causes of stroke in young)
Management - Immediate M/M; Supportive Care; Specific — Role of Thrombolysis in
Thrombotic
Events/Infarcts— When , How; M/M of HT in setting of Stroke—How to bring down BP, Any
other - Should discuss causes/Risk factors for CVA in elderly patients; Should discuss
causes/Risk factors for stroke in young patients; Should be able to identify Vascular territory;
Discussion on posterior circulation stroke should be there
Multi-valvular heart disease
History-Detailed history of symptoms– Palpitations, Dyspnoea, PND, Orthopnea, EDEMA,
Hospitalizations, Embolisations; History suggestive of RHD, other connective tissue disease, IE;
Should be able to identify-RT V/s LT sided Valve Lesions, Stenotic V/s Regurgitant Lesions
Clinical examination- Detailed ESP, GPE-Pulse(especially for)- BP, Signs of IE, Evidence of
RF, If suspected AR-Look for features of MARFAN’S, Syndrome,JVP, EDEMA; CVS –
Detailed, thorough exam of CVS-all areas; Abdomen; Fundus Exam; CNS Investigations– ECG,
Discuss Findings; CXR—Discuss Findings; ECHO—What all can be seen If
IE – Blood c/s— How many/when; RF – ASLO/CRP, other anti strept Ab
Differential diagnosis- To give diagnosis as Which all valves are involved list in order of
severity;
Etiology ( ? Rheumatic ? MARFANS etc. ); Presence/Absence of-Pulmonary A hypertension,
Congestive cardiac failure, Arrythmias/Normal Sinus Rhythm, Rheumatic Aaivety, Infective
Endo Carditis.
Management - Discuss M/m in relation of; Valve involvement- Conservative, Surgical, Others of
BMV; CHF; IE; RF; Emborisation; AF; Special Simulation eg. In Pregnancy discuss prognosis
and
outcome
Any other – Discuss-Prophylaxis for RF; IE Prophylaxis; Anticoagulation; Digoxcin-Role and
Toxicity;
M/m of Embolisation in setting of IE; Fungal Endocarditis
Cerebellar disease
History- Detailed History of Onsent, Progression of complaints; Family History – should trace
involvement in family for inherited forms of cerebellar disease; Drugs/Toxics – History
especially of
; Other Neoplasms – Paraneoplastic involvement
Clinical examination - Detailed neurological exam Especially of – CNS and also spine; Other
systemsTo be able to identify cause of cerebellar involvement.
Investigations - Role of MR/CT; Discuss findings
Differential diagnosis-Acuteonset-Chroniconset;Symmetrical - Symmetrical;Asymmetrical –
Asymmetrical.To discuss D/D according to individual situations.
Management -To identify the involvement as; Degenerative; Inherited; Drug/Toxin related;
Infective;
Vascular involvement; Paraneoplastic; M/m of individual situation
Any other -To discuss D/D appropriate IE clinical situation eg. Age.
Congenital Heart Disease
History - Onset of Symptoms – childhood, adolescence, adults; Discuss the symptoms; Cynosis –
if yes cyanotic spells feeding; Growth and milestones in children; Respiratory infection
Clinical examination-Any compiler eg. Stroke, etc.,Detailed Cardiovascular- Exam, GPE –
Sxanosis,
Cuilbbing, JVP, EDEMA; Evaluate for other inherited/congenital malformation/disorders.
Investigations – ECG; CXR; ECHO; Polycythemia/Hci; ABG
Differential diagnosis - To reach diagnosis as congenital HD. Cyanotic, Acynotic and then
further
discuss the individual differential thesis according to the case in hand; Eisenmenger – to discuss
in
detail.
Management - ISSUEO regarding; M/m of cyanotic spells(in children); M/m of CHF; M/m
relating
to; Operability; Surgery; Prognosis and Outcome
Short Case
Myopathy - Disease of Muscle/Nerve
History-History of symptoms,weakness especially, Onset, Progress, Prox V/s Distae, Severity,
Fasciculations, Atrosphy, MSI Fatigue; To identify cause if possible on history; Paraneoplastic
involvement
Clinical examination - Complete physical exam including; Detailed neurological examination;
Focus
on demonstration of (focus on LMN signs); Refrences-Planter response, Atrophy of MSIS; Skin
Exam; Spine Exam
Investigations – Discuss + CPK– total = MSL Enzymes; LDH; NCN; EMG - if NM jn – Discuss
tests for sis; MSI Biopsy
Differential diagnosis - Should be able to give D/D of LMN involvement- N,MSI and how to
differentiate,
NMJ; D/D of individual disorders eg. If muscle involvement –Myopathy,MSI Dystrophy and
then give
elistology, Myositis
Management-Depends upon clinical situation
Fibro-cavitory lung disease
History- Detailed history of Symptoms –Cough, dyspnoea/breathlessness, expectoration, fever,
edema; Past history of TB; Family history of TB
Clinical examination-GPE – Especially - Tracheal Position, cyanosis, clubbing,
lymphadenopathy,Edema, Detailed respiratory examination
Investigations- CXR; ECG; Role of CI
Differential diagnosis - Discuss complications
GENERAL GUIDELINES FOR CASE PRESENTATION AND
DISCUSSION:
Pediatric cases
History-Correct sequence of chief complaints, present history, past history, family history, birth
history,development history, socioeconomic history. All headings to be covered even if they are
normal.
However relative emphasis may be on relevant history e.g. dietary history in detail is important
in malnutrition and development history in cerebral palsy, family history in genetic disorders and
socioeconomic history in rheumatic fever etc. Emphasize on clarity of presentation and avoid
unnecessary repetition.
History of Present illness-Cover points in symptoms to find etiology of disease e.g. in failure to
thrive, whether it is a chronic illness, malabsorption, nutritional deficiency etc. Progress of the
disease eg static, improving or worsening. Secondary effects of the disease e.g. vit deficiencies in
chronic liver disease.Treatment history should be covered in detail regarding nature of medicines
e.g. tablets,injections, syrups etc and their effect on the illness. Patient may be able to tell actual
name of medicine and it should not be disregarded. Just saying that patient has taken treatment
from outside is not enough and analysis of treatment should be done. Course of the patient
during hospital stay should be also asked.
Past history -Relevant past history e.g. sore throat in Rheumatic fever etc and also generally of
common chronic diseases egg TB etc should be covered .Any prolonged illness and
hospitalization should be recorded.
SE history-Per capita income. Education of parents, type of house and other relevant details .
Dietary history-Must tell actual caloric intake .Calories of foods eaten once in 2-3 days may be
equally divided over the week egg if a banana is eaten twice a week then calories may be of 2/7
banana a day and foods eaten very occasionally may be ignored from calculation of dietary
intake.
Premorbid as well as morbid caloric intake may be asked.Try to check if anthropometry
corresponds to caloric intake as if caloric intake calculated is half of required but wt and ht are
normal ,then recheck the calculation of caloric intake and try to explain the reason.
Development history- Details of development should be asked as relevant to the case e.g. a case
of Kalazaar in 12 yr old one may ask gross mile stones only but in dev delay in 1 yr old all mile
stones in minute details may be asked.
Examination-Detailed examination of vitals, anthropometry, general physical and systemic
examination should be done. Canditate should present the involved system first. Various
techniques of examination should be checked and demonstrated during the CME.
Diagnosis and differential diagnosis-First most likely diagnosis should be told.Then diagnosis
which can not be ruled out by clinical examination but require investigations for the same should
be given.Then the similar conditions which have been clinically ruled out.
Investigations-Should be relevant to the case. Ask interpretation of investigations. Discuss x ray,
ECG , CT, ECHO findings etc.
Treatment-Discuss specific treatment. Supportive treatment. Problems in treatment regarding
side effects etc. Cost of treatment.
Prognosis-Prognosis should be discussed.
Counseling-Counseling in each case should be discussed.
Routine care –Immunization; Family welfare; Psychological aspects.