Clinical training booklet

For ERPM candidates

Recommendations by the Sri Lanka Medical Council

Clinical Medicine
Paediatrics
General Surgery
Obstetrics and Gynaecology
 General Instructions to trainees

Revision for ERPM Parts B and C, Ward based learning: Candidates sitting the ERPM Part B
(Medicine, Paediatrics, Surgery and Obstetrics & Gynaecology) and / or track of ERPM Part C
(Emergencies in the Medical Track: Medicine and Paediatrics or Emergencies in the Surgical
Track: Surgery and Obstetrics & Gynaecology) are advised to obtain practical clinical training for
a period of four (X 4) weeks at a Consultant Unit in a Provincial / Base Hospital (where there are
no medical undergraduates from state Medical Faculties) under the supervision of the
Consultant in charge of the relevant subject. The training should deal with the more clinical
areas such as routine clinical care provided at outpatient and inward. The trainees however
should appreciate that these are an extension of the theoretical aspects of the various
conditions which include the basic sciences (anatomy, physiology, pathophysiology, micro-
biology, pharmacology etc).

Trainees should follow the following rules and guidelines during the training period:

1. Follow a Dress Code that would be appropriate for a Sri Lankan hospital setting. Trainees
should be neatly dressed and wear a white coat within the hospital premises.
2. Report to the Consultant at the beginning of the training for introduction and preliminary
instructions.
3. Use the opportunities provided for maximum learning from the clinical scenarios present
under the guidance and supervision of the Consultant in charge.
4. Trainees are expected to follow an ethical code of behavior and respect the privacy and
dignity of the patients including gender based privacy. Always seek permission to examine
either from the patient or in ill patients from the by-stander / relative.
5. Trainees are expected to display empathy in an appropriate manner based on the patients
situation.
6. Trainees should be polite and non aggressive in their interactions with staff and patients.
They should display an etiquette as expected of a Medical Practitioner, such as proper
introduction of themselves and expressing their thanks whenever it is due etc.
7. Respect the status of and maintain a cordial relationship with all staff as an exercise of
team participation in patient care. They could help you with your learning.
8. Note that the Sister in Charge of the ward is overall responsible for its day to day
administration and would therefore overlook the trainees conduct within the ward and
report to the Consultant any issues of concern.
9. The trainees should make their own arrangements for Travel and accommodation.
10. The Consultants recommendation taking into account the attendance, completion of
procedures and behavior would be valuable for future professional development.

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CLINICAL TRAINING IN MEDICINE
Name of Supervising Physician:...

Dates of training: From .. (mm/dd/yyyy) to . (mm/dd/yyyy)

Ward number(s): Hospital:..

GENERAL OBJECTIVES

The candidate should be able to

1. Be responsible for the well-being of the patient assigned to him/her and work independently as
a house officer under supervision.
2. Be competent in the technique of history taking, physical examination, identify the problems
and clinical reasoning, come to a reasonable diagnosis/differential diagnoses, write a concise
summary and plan management at a level expected of a basic primary care doctor.
3. Competently document case notes and write discharge summaries.
4. Evaluate patients with common diseases (annex 1) in a rational, analytical way with a view to
problem-solving (clinical reasoning).
5. Describe and relate knowledge of basic sciences and epidemiology to clinical situations and
explain pathophysiological basis of diseases, judge the prognosis, and plan out investigations
and treatment strategies.
6. Perform common diagnostic and therapeutic procedures (annex 2) and state their indications,
limitations and undesirable effects.
7. Manage common medical emergencies (annex 3) and perform life-saving therapeutic
procedures and common diagnostic procedures.
8. Organize preparation and transport of specimens (including special situations such as suspected
viral hepatitis and HIV).
9. Interpret routine investigation results (laboratory, radiological, electrocardiography and others).
10. Competently state a reasonable clinical differential diagnosis, plan out a logical strategy to
investigate further and suggest pharmacological and non-pharmacological management
including preventive measures.
11. Communicate well with patients their families from different social and cultural backgrounds
with particular reference to giving information, obtaining consent and breaking bad news.

SPECIFIC OBJECTIVES

The candidate should be able to

1. Obtain a comprehensive and accurate history, giving due attention to onset and development of
symptoms, past medical and surgical history, drug and allergy history, dietetic history, family
history and social background.

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2. perform a comprehensive clinical examination that includes general examination and the
examination of the following;
head and neck
cardiovascular system
respiratory system
neurological system
abdomen and rectal examination
skin
musculoskeletal system
haematology and lymphatic system
other relevant systems (eg. endocrine)
3. Perform competently the following techniques;
measurement of the blood pressure
ophthalmoscopy
auroscopy
4. Identify and prioritize the patient's medical, social and cultural problems.
5. Analyze the symptoms and physical signs and arrive at a rational differential diagnosis.
6. Explain the clinical features on a pathophysiological basis, predict the natural course of the
illness and the prognosis.
7. Map out a plan for further investigations while paying due attention to the benefit, risks and
costs.
8. Document clearly the findings of history taking, physical examination, summary, plan for
investigations and results, plan for treatment and the daily progress.
9. Competently interpret basic laboratory investigations, radiological and electrocardiographically
abnormalities.
10. Pay attention to the special needs of the elderly patients, assess activities of daily living, pay
attention to the premorbid state of the patient and the level of care available at the family level.
11. Identify and arrive at a practical diagnosis (or a differential diagnosis) and manage following
medical emergency presentations/ diseases;
cardiac arrest
chest pain
shock
acute breathlessness
unconscious patient
haematemesis
acute neuromuscular paralysis
anaphylaxis
seizures and status epilepticus
snake bite envenoming
acute myocardial infarction
other acute coronary syndromes

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 acute left ventricular failure
arrhythmia
hypertensive emergencies
acute severe asthma
pneumothorax
diabetic ketoacidosis
hypokalaemia and hyperkalaemia
stroke
acute renal failure
poisoning (eg: organophosphate poisoning, paracetamol overdose, plant poisoning)
sepsis with multi-organ failure
meningitis
12. Plan the non-pharmacological and pharmacological management on a rational basis, giving
due attention to effectiveness, side effects, interactions and the cost of the pharmacological
agents.
13. Perform the following;
peak flow rate assessment
basic urine analysis
12-lead ECG
intravenous, intramuscular and subcutaneous injections
capillary blood sugar testing using a glucometer
intravenous cannulation
set up an intravenous infusion and a blood transfusion
cardiopulmonary resuscitation
defibrillation
nasogastric tube insertion
urinary catheterization
nebulization
monitor Glasgow Coma Scale
maintain a fluid balance chart
measure and chart temperature
20-minute whole blood clotting test
collect and transport specimens for microbiological investigations
group and direct test for blood transfusion and set-up a blood transfusion
obtain (eg: by venepuncture) and prepare samples of body fluid for appropriate
tests such as peripheral blood film, blood culture, urine culture
assess a patient with impending respiratory failure and on a ventilator
14. Observe the following procedures under direct supervision or on a model and state their
relevance in diagnosis, prognostication and management;
endotracheal intubation

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 arterial blood gas analysis
lumbar puncture
cardioversion
pleural aspiration
peritoneal tap
peritoneal dialysis
enema
basic physiotherapy
15. Describe the following procedures and state their relevance in diagnosis, prognostication and
management;
insertion of a central venous line
haemodialysis
liver biopsy
renal biopsy
pleural biopsy
mechanical ventilation
gastrointestinal endoscopy and bronchoscopy
pituitary and adrenal function tests
aspiration of a joint and intra-articular injection
contrast studies of the gastrointestinal and genitourinary tracts
EEG, EMG and nerve conduction studies
echocardiogram, Exercise Stress ECG, Coronary Angiogram, Holter monitoring
spirometry
bone marrow aspiration and biopsy
haemodialysis
16. Write concise, clear and informative discharge summaries and referral notes.
17. Communicate effectively with patients and empathize with patients and their families when
giving information about the illness, prognosis, preventive and offer health educational advice.
18. Break bad news humanely and accurately giving due consideration to the sensitive nature of the
information under supervision and on simulated patients.
19. Recognize medico-legal issues that may arise during management and reason out the ethical
issues that concern patients and the health care providers.
20. Appreciate the different roles played by the members of the health care team, organization of
the administrative structure, administrative procedures, the place of ambulatory care provided
by the out-patient clinics, functions of other health care providers in the community and the
preventive services.
21. Develop the skills and attitudes of a life-long self-directed learner and participate in group
activities such as journal clubs, clinic-pathological meetings, audit meetings and clinical case
conferences.
22. Function as a member of a team in the ward setting and acquire leadership skills.

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ATTENDANCE RECORD
Date Signature certifying attendance
1.
2.
3.
4.
5.
6.
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8.
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10.
11.
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14.
15.
16.
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CHECKLIST
Performed the following* 1 2 3 4
Presented complete history
Designation
Date
Presented complete system examination findings
Designation
Date
Venepuncture
Designation
Date
Collected and dispatched samples to hospital lab
Designation
Date
Administered iv injection
Designation
Date
Administered IM injection
Designation
Date
Administered SC injection
Designation
Date
Inserted an iv cannula
Designation
Date
Inserted a NG feeding tube
Designation
Date
Carried out in-ward urine tests
Designation
Date
Inserted an urinary catheter
Designation
Date
Observed the following 1 2 3 4
Lumbar puncture
Designation
Date
Gastric lavage
Designation
Date

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Pleural aspiration
Designation
Date
Peritoneal tap
Designation
Date
Pleural biopsy
Designation
Date
Bone marrow biopsy
Designation
Date
Cardio-pulmonary resuscitation
Designation
Date
Insertion of peritoneal catheter
Designation
Date
* First row for each item to be initialed by VP/SR/SHO

I hereby certify that the candidates attendance and performance has been satisfactory during
the period of training.

Signature of supervising Physician

Name of supervising Physician .

Date: .

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CLINICAL TRAINING IN PAEDIATRICS

Supervising Paediatrician: ..

Dates of training: From . (mm/dd/yyyy) to .. (mm/dd/yyyy)

Ward number(s): Hospital:

LEARNING OPPORTUNITIES

To learn care of children, the following settings are available in the hospitals:-
1. Paediatric wards and postnatal wards
2. Emergency Treatment Unit (ETU)
3. Special Care Baby Unit and Neonatal Intensive Care Unit (SCBU and NICU)
4. Delivery Room and Operating Theatre
5. Paediatric Clinics
6. Laboratory, Radiology Department, Physiotherapy Unit, Speech and Language Unit,
Indoor and Outdoor Pharmacies
RESOURCES
Consultants and other medical staff, Sisters and Nurses, Midwives, Attendants and other staff in
wards, clinics, delivery rooms and theatre.
Para Medical Services:
Physiotherapist, Occupational and Speech Therapist, Radiographers
Patients and the caregivers are the most important resources for learning

Trainee should
1. Observe preparation in the delivery room for birth and immediate care of new born
baby
2. Learn immediate care of the new born baby

3. Discuss and describe current recommendations and advantages of breast feeding, skin
to skin care etc of new born

4. Attend postnatal ward rounds and perform neonatal examination, maturity assessment
and describe routine care of new born

5. Talk to mothers on breast feeding, identify problems if present and learn about support
services available for promotion of breast feeding

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6. Visit Lactation Management Centre and discuss with relevant officers and observe
advise given to mothers

7. Learn practical aspects of resuscitation of an asphyxiated new born.

8. a. Identify clinical features and complications of common neonatal problems in Sri Lanka
and describe their management and prevention (low birth weight, preterm, respiratory
distress, jaundice, sepsis, meningitis, hypothermia, hypoglycaemia, hypocalcaemia,
seizures and surgical problems) and, briefly explain the pathophysiology of the above
conditions.
b. Describe important surgical problems encountered in newborn and their immediate
management eg. tracheo oesophageal fistula, imperforate anus, diaphragmatic hernia.

9. Attend Well Baby and At Risk Baby Clinic. Advise mother on infant nutrition including
breast feeding, complementary feeding and describe recommended diets (specifying
food items) for healthy infants and preschool children.

10. Recognize the pattern of normal postnatal growth and identify abnormalities such as
failure to thrive, obesity and describe the causes and management.

11. Assess development of the infant and preschooler specifying important mile stones and
recognizing deviations from the normal.

12. Describe primary child health strategies recommended in Sri Lanka eg. National
Programme of Immunization, growth monitoring, use of CHDR, vitamin and nutrition
supplementation programmes etc.

13. Name the vaccines in the National Program of Immunization (NPI) in Sri Lanka, vaccine
storage conditions, the sites, routes and age of administration, adverse effects and its
notification. Name important non NPI vaccines. (visit area MOH)

14. Learn to recognize and manage common paediatric clinical problems and complications
and emergency care
Learn long term follow up and prevention when relevant.
Learn aetiology and prognosis of these conditions
a. Take a relevant paediatric clinical history, identify and prioritize the information.
b. Conduct a systematic clinical examination including growth parameters and
development assessment. (A child and parent friendly approach is necessary).
c. List the relevant diagnostic investigations and interpret the results of a given
clinical situation.
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 Common Paediatric problems
i. CVS - common congenital and acquired heart diseases.
ii. RS - Recognize and manage acute respiratory infections including bronchiolitis,
pneumonia, stridor and upper respiratory infections. Describe X ray changes seen in
common respiratory conditions of children.
iii. Diagnose and manage bronchial asthma and describe precipitating factors, assessment
of severity, treatment options and pharmacological and non pharmacological strategies
of asthma control.
iv. List the pathogens causing diarrhoeal diseases in children in Sri Lanka. Diagnose and
manage diarrhea including assessment of level of hydration and fluid therapy.
v. Common renal disorders such as urinary tract infections, acute glomerulonephritis,
nephrotic syndrome, acute and chronic renal failure.
vi. Common neurological disorders and their complications. Eg febrile convulsion and other
seizure disorders, meningitis, encephalitis and encephalopathies, acute flaccid paralysis,
cerebral palsy, hydrocephalus, microcephaly.
vii. Common developmental disorders such as mental retardation, cerebral palsy.
viii. Behavioural and psychiatric disorders in childhood e.g. autism, ADHD, enuresis,
tantrums, psychosomatic disorders and other behaviour disorders.
ix. Endocrine and metabolic disorders such as congenital hypothyroidism, diabetes mellitus
and inborn errors of metabolism.
x. Haematological conditions (eg. deficiency anaemia, haemolytic diseases encountered in
Sri Lanka, immune thrombocytopenic purpura, haemophilia, aplastic anaemia and
haematological malignancies) and immunological (hypersensitivity and immune
deficiency)
xi. Be familiar with procedures involved in administration of blood and blood products.
xii. Common childhood malignancies especially leukaemias and common solid tumours
(brain, renal, bone).
xiii. Musculoskeletal disorders in children.
xiv. Describe genetic and chromosomal abnormalities, inheritance patterns, pedigree charts
and risk assessment of common genetic diseases.
xv. Dermatological conditions in childhood (atopic dermatitis, urticaria, scabies, impetigo,
fungal infections and head lice etc) and recognize viral exanthems.
xvi. Recognize and manage common childhood complaints such as infantile colics, recurrent
abdominal pain, constipation, limb pain etc.
xvii. Describe important surgical problems of infants and children including hypertrophic
pyloric stenosis, intussusceptions, volvulus, hernia and hydrocoele.
xviii. Recognize and describe the immediate management of common paediatric emergencies
such as coma, stridor, anaphylaxis, severe dehydration and hypovolaemic shock, dengue

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 shock syndrome, cardiac failure, status epilepticus, acute severe asthma, diabetic
ketoacidosis, hypertensive encephalopathy, snake bite.
xix. Be familiar with the most recent National Guidelines on Management of Dengue Fever
and Dengue Haemorrhagic Fever in Children.
xx. Attend a course held by Sri Lanka College of Paediatricians to learn the principles of
basic and advanced life support in paediatrics and neonatal life support
xxi. List medications that should be available on the emergency trolley and be familiar
with the dosages of emergency/life saving medications such as adrenaline,
hydrocortisone, diazepam, dextrose, amioderone, normal saline, aminophyllin,
frusemide, phenytoin sodium etc.
xxii. Be familiar with clinical procedures commonly carried out in a paediatric ward such as
administration of oxygen, nebulization, intravenous cannulation, lumbar puncture,
naso-gastric feeding, airway management etc.
xxiii. Describe the contraindications and common/important adverse effects of routinely used
medications in paediatric practice and name the sources from where drug information
can be obtained regarding paediatric prescribing.

15. Describe the epidemiology of common/important communicable diseases among

children in Sri Lanka and explain their pathophysiology, clinical features, complications
management and prevention.
e.g. acute gastro-enteritis, respiratory tract infections, mycoplasma infection, dengue,
meningitis, encephalitis, typhoid hepatitis, tuberculosis, leptospirosis, whooping cough,
infectious mononucleosis, measles, rubella, mumps, chicken pox, rabies, HIV etc.
List diseases those are notifiable in Sri Lanka and different mechanisms of notification.

16. Recognize and manage other infections that cause outbreaks among children in Sri
Lanka. Eg SARS, H1N1, Hand foot mouth disease, chikungunya etc

17. Describe the epidemiology of non-communicable diseases in the paediatric age group in
Sri Lanka and be able to diagnose, treat, prevent and advice on prognosis of same.

18. Identify common nutritional problems in Sri Lanka e.g. protein energy malnutrition,
obesity, iron deficiency, iodine deficiency, vitamin A deficiency and other micro nutrient
deficiencies and describe their predisposing causes, presentations, management
(including therapeutic foods, food supplements and rehabilitation) and prevention .

19. Be familiar with the risk factors and management of road traffic and home accidents,
poisoning (eg kerosene oil ingestion and paracetamol over dosage), insect stings and
animal bites (dog & snake).
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20. Describe presentations of child abuse including physical, emotional and sexual abuse
and be familiar with issues related to child rights and child protection.

21. Break bad news to parents in the event of a childs death, serious illness or disability.

22. Show familiarity with cultural habits, beliefs and alternative healing methods practiced
in Sri Lanka.

23. Describe environmental hazards such as air & water pollution and mosquito & fly borne
diseases and their impact on child health.

24. Describe the current morbidity and mortality patterns in paediatrics in Sri Lanka
(perinatal, neonatal, infant under five mortality etc), their trends, underlying causes and
interventions towards improvement.

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ATTENDANCE RECORD
Date Signature certifying attendance
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

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CHECKLIST
Performed the following Signature* Desig Date
Completed 10 paediatric case histories
Completed 2 neonatal case histories
Presented one paediatric case history
Performed under supervision
One routine newborn examination
One developmental assessment
Observed the following
Venepuncture
Setting up iv drip
Administration of IM injection
Administration of SC injection
Nebulization
Setting up of a blood transfusion
Phototherapy
Neonatal resuscitation
Vaccination
Insertion of oro/naso-gastric tube
Gastric lavage
ET tube ventilation
Lumbar puncture
Exchange transfusion
Insertion of intercostal tube
Filled in the following forms
Biochemistry request form
Haematology request form
Microbiology request form
X-ray
ECG
EEG
Observed appropriately filled forms
Transfer form
Notification of communicable diseases
Death certificate
*Consultant / Registrar / SHO
I hereby certify that the candidates attendance and performance has been satisfactory during
the period of training.

Signature of supervising Paediatrician..

Name of Supervising Paediatrician ..
Date: .

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CLINICAL TRAINING IN SURGERY

Dates of training: From (mm/dd/yyyy) to . (mm/dd/yyyy)

Ward number(s): Hospital:

INTRODUCTION

The surgical curriculum provides the frame work to guide the students to prepare for the ERPM
examination.
Under each content area, the learning objectives, expected core knowledge and clinical skills
required for the students to practice surgery at the level of an intern medical officer in Sri Lanka
are highlighted.
Procedural skills are listed separately.
It is expected that the student is competent in arriving at the most likely clinical diagnosis,
assessment of the severity, deciding on the appropriate treatment strategy of surgical
emergencies and common surgical conditions at the level of an intern house officer.
It is also expected that, other than the diagnosis and treatment, the student understands the
need to communicate with patients & relatives respecting their dignity, rights, fears &
anxieties, taking in to consideration the socio-economic, cultural, religious & educational
background of the patients.

LEARNING OBJECTIVES AND CONTENT AREAS

Content areas
Assessment of the acute abdomen, Gastrointestinal haemorrhage , Strangulated hernia,
Superficial sepsis including necrotizing infection Critically injured patient ATLS
approach,Vascular emergencies, Elective vascular conditions, Conditions affecting the scrotum,
Conditions affecting the genito urinary system, Elective hernia, Endoscopy, Oesophago-gastric
disease, Diseases of the Small bowel, Hepato-pancreato-biliary disease, Colonic and anorectal
disease, Endocrine glands and their diseases, Conditions affecting the breast, Diseases affecting
the oral cavity and salivary glands, Common skin and soft tissue conditions of surgical
importance, Bone and joint infection, Fractures and dislocations, Dying patient

ASSESSMENT OF THE ACUTE ABDOMEN

Learning objectives
Assessment, resuscitation and management of patients with acute abdomen

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Core knowledge
Differential diagnosis, Treatment of intraperitoneal sepsis, Principles of management of bowel
perforations, Principles of damage control surgery

Clinical skills
Clinical diagnosis, Resuscitation, antibiotic therapy, Management of associated medical
conditions, Recognition of the indications for surgery

PERITONITIS

Learning objectives
Diagnosis and management of peritonitis

Core knowledge
Causes, Patho-physiology, Complications, Treatment of intraperitoneal sepsis and systemic
sepsis

Clinical skills
History, examination and eliciting/interpreting physical signs, Clinical assessment of severity of
the illness, Interpretation of investigations, Timing of intervention

GASTROINTESTINAL HAEMORRHAGE

Learning objectives
Diagnosis and emergency management of patients with acute gastro intestinal haemorrhage,
Recognition of causes, Surgical treatment of GI bleeding and post-operative management,
Management of complications of GI bleeding

Core knowledge
Assessment of severity, Management of blood loss, Identification of the aetiology, Patho-
physiology of hypovolaemia, Treatment options; role and timing of endoscopic treatment,
Indication for surgical management, Post operative care, complications and their management

Clinical skills
Recognition of the degree of blood loss and severity of co-morbid disease, Recognition of re-
bleeding and complications

ACUTE INTESTINAL OBSTRUCTION

Learning objectives
Diagnosis and management of acute intestinal obstruction

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Core knowledge
Aetiology, Classification, Differential diagnosis, Treatment options, non operative / operative,
Principles of surgery

Clinical skills
Clinical diagnosis and assessment (identification of strangulated from simple, adynamic from
mechanical, large bowel from small bowel obstruction; specific causes i.e adhesions, volvulus),
Clinical assessment of fluid loss, resuscitation, recognition of those who need intensive care,
Interpretation of radiographs, laboratory investigations, Role of contrast CT scan

STRANGULATED HERNIA

Learning objectives
Management of strangulated hernia

Core knowledge
Surgical anatomy of the inguinal region, femoral canal, abdominal wall and sites of internal
herniation, Patho-physiology of strangulated hernia, Principles of surgery, Post operative
complications,

Clinical skills
Clinical diagnosis and assessment of strangulated herniae of all types, Appropriate
investigations, Resuscitation

SUPERFICIAL SEPSIS, NECROTIZING INFECTIONS AND TETANUS

Learning objectives
Diagnosis and treatment of simple and complicated soft tissue infections including life
threatening soft tissue sepsis and tetanus

Core knowledge
Recognition and management infective conditions of the skin i.e infected sebaceous cyst,
carbuncle, superficial abscess, cellulitis, infected ingrown toe nail, paronychia, pilonidal sinus,
intermammary sinus and hidradenitis suppurativa, Vulnerable individuals / Predisposing
factors, Recognition and management of gas gangrene, other necrotizing infections and
tetanus, Management of diabetes mellitus, Patho-physiology of septic shock, Appropriate
antibiotic therapy

Clinical skills
History, examination, Recognition of the early warning features of life threatening soft tissue
infections and tetanus, Resuscitation, antibiotic therapy and recognition of the need for
intensive care for life threatening soft tissue infections and tetanus

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EMERGENCY / TRAUMA

Learning objectives
Initial management of critically injured patient

Core knowledge
Mechanism of injury, causation, injury patterns, Pathogenesis of shock, Basic patho-physiology
of head injury, chest injury, haemorrhage, septic shock, Complications of bone and joint injury,
Complications of vascular injury, Hypothermia, electrocution, burns, Initial management of all
forms of trauma and definitive management of abdominal trauma

Clinical skills
Initial assessment and resuscitation based on ATLS principles, Recognition of the need for
intervention, Principle of Triage

VASCULAR EMERGENCIES

Learning objectives
Diagnosis and management of peripheral vascular emergencies, Prevention, diagnosis and
management of DVT

Core knowledge
Aetiology and natural history of common vascular emergencies and emergency and definitive
management, peripheral vascular injuries, thrombo-embolism, thrombosis and superficial
thrombophlebitis, Clinical features, investigations and treatment of DVT, prevention and follow
up

Clinical skills
Resuscitation, Interpretation of investigations, Decision to amputate - life versus limb

ELECTIVE VASCULAR CONDITIONS

Learning objectives
Diagnosis and management of varicose veins and peripheral vascular disease

Core knowledge
Venous drainage of lower limb, clinical features, complications, investigations and treatment of
varicose veins, Clinical features, complications, investigations and principles of treatment of
chronic occlusive vascular disease of the limbs

Clinical skills
Clinical diagnosis, Interpretation of investigations, Assessment of the extent and severity of the
disease, Non operative management, life style changes
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CONDITIONS AFFECTING THE SCROTUM

Learning objectives
Diagnosis and treatment of the conditions affecting the scrotum

Core knowledge
Causes of acute scrotal pain, Predisposing factors and patho-physiology of torsion of the testis,
Clinical features of hydrocoele, cyst of the epididymis, varicocoele, spermatocoele and
haematocele, Undescended testis, Types of Testicular tumours, Aetiology and differential
diagnosis of epididymo-orchitis

Clinical skills
History, examination and eliciting/interpreting physical signs, Clinical diagnosis of torsion of
testis, Diagnosis of testicular malignancies, Clinical diagnosis of obstructed/strangulated groin
hernia

DISEASES AFFECTING THE BLADDER AND URETHRA

Learning objectives
Diagnosis and management of acute and chronic retention of urine, Lower Urinary Tract
Symptoms (LUTS), Recognition of traumatic injuries to bladder and urethra, Principles of
management of bladder neoplasms

Core knowledge
Aetiology, clinical features and complications of acute and chronic, retention of urine,
Conditions affecting the bladder and urethra presenting with haematuria including transitional
cell tumors, Treatment of acute and chronic urinary obstruction

Clinical skills
History, examination, Interpretation of investigations

DISEASES AFFECTING THE MALE GENITALIA

Learning objectives
Assessment and treatment / referral of conditions affecting the glans penis and foreskin

Core knowledge
Clinical features, complications and principles of management of and carcinoma of the penis

Clinical skills
Clinical diagnosis

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DISEASES AFFECTING THE KIDNEYS AND URETERS

Learning objectives
Diagnosis and management of upper and lower urinary tract obstructions / infections,
Diagnosis and management urinary stone disease, Diagnosis of urological malignancy and
treatment

Core knowledge
Aetiology, Clinical features, microbiology and complications of urinary tract infections,
Investigations, Antibiotics and relevant pharmacology, Aetiology, clinical features,
complications and initial treatment of urolithiasis

Clinical skills
Diagnosis of obstructed / infected kidney, Emergency treatment

ELECTIVE HERNIA

Learning objectives
Diagnosis and management abdominal wall hernia

Core knowledge
Anatomy of inguinal and femoral region, abdominal wall and related structures, Natural history,
presentation of abdominal herniae and complications, Treatment options, Current methods of
operative repair including open mesh, laparoscopic mesh,

Clinical skills
Diagnosis, assessment of patients presenting with herniae including inguinal, femoral,
incisional, paraumbilical hernia, Post operative management and advice

ENDOSCOPY

Learning objectives
Safe performance of upper and lower GI endoscopy including colonoscopy

Core knowledge
Indications for flexible / rigid oesophagoscopy, proctoscopy, rigid / flexible sigmoidoscopy, rigid
/ flexible cystoscopy, Indications for colonoscopy, Consenting for endoscopy, Sedative and
analgesic drugs and side effects, Recognition of complications of endoscopy

Clinical skills
Recognizing indications, risks and benefits of endoscopy /endotherapy

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OESOPHAGO-GASTRIC DISEASE

Learning objectives
Diagnosis, basic principles of management of peptic ulcer disease, gastritis, gastro-oesophageal
reflux disease, oesophago-gastric neoplasms

Core knowledge
Clinical features, complications and principles of treatment of peptic ulcer, gastro-oesophageal
reflux disease and gastritis including Helicobacter pylori, clinical features of oesophageal and
gastric malignancies, Investigations, Indications for surgery, Non surgical treatment

Clinical skills
History, examination, Investigations

DISEASES OF THE SMALL BOWEL

Learning objectives
Diagnosis and management of benign and malignant conditions of the small bowel

Core knowledge
Clinical features, pathology and management of intussusception in children and in adults,
Clinical features, pathology, complications and management of post operative small bowel
adhesions, Usefulness and limitations of investigations

Clinical skills
Clinical diagnosis, Interpretation of investigations, Decision making regarding laparotomy

HEPATO-PANCREATO BILIARY DISEASE

Learning objectives
Diagnosis and management of gallstones and its complications, Diagnosis and management of
extrahepatic biliary obstruction, Diagnosis and management of acute pancreatitis, chronic
pancreatitis, and their complications, Diagnosis and management of benign and malignant
pancreatic tumours, Diagnosis and management of benign and malignant liver
tumours/infections

Core knowledge
Aetiology, clinical features, complications and management of gallstones, Causes, natural
history, complications and management of obstructive jaundice, Aetiology, clinical features,
pathophysiology ,complications and management of acute pancreatitis, Clinical features natural
history and management of benign and malignant pancreatic tumours, Aetiology, clinical
features and management of liver tumours

23
Clinical skills
Clinical diagnosis, Investigations, Assessment of severity of acute pancreatitis, recognition of
patients needing intensive care, antibiotics, Liaising with relatives

COLONIC AND ANO RECTAL DISEASES

Learning objectives
Diagnosis and management of acute appendicitis, colonic infections, diverticular disease,
sigmoid volvulus, ano-rectal suppuration, inflammatory bowel disease, haemorrhoids, anal
fissure/fistula in ano, Diagnosis and management of colorectal neoplasia

Core knowledge
Aetiology, pathology, clinical features and complications of acute appendicitis, diverticulitis,
and ano- rectal suppuration and fistulous disease, Pathology, and clinical features complications
of inflammatory bowel disease, medical management and indications for surgery,
Epidemiology, aetiology, pathology and management of colorectal and anal neoplasia, pre
malignant conditions and polyps and including screening for colorectal cancer, Aetiology,
clinical features, and basic principles of management of anal fissure, and haemorrhoids

Clinical skills
Clinical diagnosis, Investigations, Staging of neoplastic disease

ENDOCRINE GLANDS AND THEIR DISEASES

Learning objectives
Diagnosis and management of diseases of the thyroid gland, parathyroid glands, adrenal glands

Core knowledge
Aetiology, pathology, pathophysiology, clinical features, complications and management of
diseases affecting the thyroid gland, Clinical features of parathyroid, adrenal tumours

Clinical skills
Clinical diagnosis, Interpretation of investigations

CODITIONS AFFECTING THE BREAST

Learning objectives
Diagnosis and management of benign breast diseases and breast cancer including screening for
breast cancer

Core knowledge
Clinical features, pathology, natural history and management of breast infections, benign breast
disease, and breast cancer.
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Clinical skills
Clinical diagnosis, Triple assessment

DISEASES AFFECTING THE ORAL CAVITY AND SALIVARY GLANDS

Learning objectives
Management of benign and malignant diseases of the salivary gland, Common benign pre
malignant and malignant conditions of the oral cavity

Core knowledge
Clinical features, principles of treatment of benign and malignant tumours of the salivary
glands, pathology, clinical features, investigation and treatment of malignant tumours of the
tongue and the oral cavity

Clinical skills
Clinical diagnosis, Interpretation of investigations, Referral, Construction of a feeding
jejunostomy, feeding gastrostomy

COMMON SKIN AND SOFT TISSUE CONDITIONS OF SURGICAL IMPORTANCE

Learning objectives
Diagnosis and management of common skin and soft tissue conditions of surgical importance

Core knowledge
Clinical features, pathology, complications and natural history of sebaceous cyst, implantation
dermoid, callosity, ganglion, Clinical features and pathology of carpal tunnel syndrome
tenosynovitis, and bursitis, Clinical features of pigmented naevi, malignant melanoma, senile
keratoses, squamous cell carcinoma of skin and basal cell carcinoma, Clinical features,
pathology, natural history lipoma / fibroma / neurofibroma / leiomyoma,/ rhabdomyoma and
sarcomatous tumors, Clinical features, pathology, complications of capillary haemangioma,
cavernous haemangioma, cystic hygroma, branchial cyst and congenital dermoids

Clinical skills
Clinical diagnosis, Investigations

25
BONE AND JOINT INFECTION

Learning objectives
Diagnosis and management of acute bone and joint infection.

Core knowledge
Aetiology, clinical features, microbiology and pathology of bone and joint infection,
Investigations, Treatment options

Clinical skills
Clinical diagnosis of acute and chronic bone and joint infection

LIMB TRAUMA

Learning objectives
Diagnosis and basic principles of management of closed and open fractures

Core knowledge
clinical features, investigation and principles of treatment of fractures and dislocations

Clinical skills
Clinical diagnosis of fractures, dislocation and recognition of early complications, Interpretation
of investigations, radiological description of the fracture / dislocation, Three Ps, Preserve life
and limb, Prevent further injury, Promote pain relief and recovery

MANAGEMENT OF THE DYING PATIENT

Leaning objectives
Appropriate palliative care of the dying patient and counseling of the relatives

Core knowledge
Methods of effective pain relief, anti-emesis and purgation, Principles of nursing care
Diagnosis of brain death, Role of the coroner and certification of death

Clinical skills
Prognostication, Issue of do not resuscitate order (DNR), Counseling of patients and relatives,
development of communication skills, Liaise with palliative care team / pain team / clergy /
legal officers

PROCEDURAL SKILLS
Intramuscular injections, Intravenous injections, Sub-cutaneous injections, Drawing blood for
investigations, IV cannulation and setting up a drip, Setting up a blood transfusion,
Catheterization male, Catheterization female, Suturing a wound, Scrubbing in the theatre,
Removal of a drain, Insertion of a nasogastric tube, Wound dressing, Writing an Operation note,
Writing a diagnosis card, Obtaining consent for surgery

26
ATTENDANCE RECORD
Date Signature certifying attendance
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

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CHECKLIST
Performed the following* 1 2 3 4 5
Presented complete history
Designation
Date
Presented examination findings
Designation
Date
Assessed trauma patients and maintained vital signs
Designation
Date
Performed venepuncture
Designation
Date
Inserted an iv cannula
Designation
Date
Setup an iv infusion
Designation
Date
Scrubbed up in OT
Designation
Date
Prepared preoperative checklist
Designation
Date
Inserted urinary catheter
Designation
Date
Removed indwelling urinary catheter
Designation
Date
Sutured wounds
Designation
Date
Maintained Glasgow coma scale
Designation
Date
* First row for each item to be initialed by VP/SR/SHO/ Nurse
I hereby certify that the candidates attendance and performance has been satisfactory during the
period of training.
Signature of supervising Surgeon
Name of supervising Surgeon Date:

28
CLINICAL TRAINING IN OBSTETRICS & GYNAECOLOGY

Name of supervising VOG:.

Dates of training: From . (mm/dd/yyyy) to . (mm/dd/yyyy)

Ward number(s): Hospital:

COMPETENCIES IN OBSTETRICS:
1. History-taking and examination of an Obstetric Patient and interpretation of
findings. (Both uncomplicated and complicated)
2. Interpret investigations in relation to obstetric care.
3. Labour Management- Maintaining Partogram, Conducting normal deliveries,
suturing episiotomy and perineal tears.
4. Assessment of the new born-APGAR, maturity
5. Understand the principles of following procedures by observation and assisting:
6. Instrumental deliveries- Vacuum and forceps deliveries,
7. Vaginal Breech deliveries, Twin deliveries, Manual removal of placenta, Caesarean
deliveries, suturing tears in the genital tract.
8. Candidate should be able to manage the following obstetric emergencies: Ante
partum haemorrhage, hypertensive emergencies, fetal distress, cord prolapse,
Obstructed labour, shoulder dystocia, Uterine inversion, Uterine rupture, primary
and secondary post partum haemorrhage, post partum collapse, Retained placenta,
Acute liver problems in pregnancy, venous thrombo-embolism and septicaemia.

COMPETENCIES IN GYNAECOLOGY:
1. History taking and examination of a Gynaecological Patient and interpretation of
findings
2. Interpret investigations in relation to Gynaecological care
3. Able to perform following procedures: Pap smear, High vaginal swab, IUCD
insertion.
4. Understand the principles of the following common gynaecological procedures by
observing and assisting: Dilatation and curettage, Dilatation and evacuation,
Evacuation of retained products of conception, HSG, LRT, Abdominal and Vaginal
hysterectomies, Myomectomy, Laparoscopy and laparotomy.
5. Candidate should be able to manage the following gynaecological emergencies:
Ectopic pregnancy, ovarian cyst accidents, septic abortions and bleeding associated
with miscarriage, hyperemesis gravidarum.

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OBSTETRICS - CONTENT AREA:
Physiology of pregnancy, Antenatal care, Management of labour and puerperium, Obstetric
haemorrhage, coagulation defects, Rhesus iso-immunization, Medical disorders in
pregnancy, Abnormal labour, multiple pregnancy, malpresentations and mal positions,
Operative interventions in obstetrics and their complications, Obstetric emergencies*,
Pre-pregnancy counseling, prenatal diagnosis, early pregnancy problems, intrauterine
growth restriction, fetal surveillance, Neonatal care, pre term labour, pre mature rupture
of membranes, infections in relation to pregnancy, prescribing in
pregnancy, Maternal and Perinatal statistics.

GYNAECOLOGY - CONTENT AREA:

Clinical anatomy and physiology relevant to gynaecology, endocrinological disorders,
Disorders of Sexual differentiation, early pregnancy problems, gynaecological
emergencies*, gynaecological malignancies, Benign tumours in Gynaecology, infertility,
contraception, infections in gynaecology, infertility, Menstrual cycle and its disorders,
endometriosis and adenomyosis, Menopause and hormone replacement therapy, Uro
gynaecology, genital prolapse, pre and post operative care, operative procedures in
gynaecology.
Based on the above curriculum, the candidate should demonstrate adequate:
i. Knowledge
ii. Application of knowledge and problem solving
iii. Clinical skills
iv. Procedural Skills
v. Choosing relevant investigations
vi. Drugs and drug doses of important areas
vii. Handling of emergencies

LEARNING OPPORTUNITIES
The following settings are available in the hospitals for learning:-
7. Obstetric and Gynaecology clinics, Antenatal and Postnatal wards
8. Delivery Room and Operating Theatre
9. Emergency Treatment Unit (ETU)
10. Special Care Baby Unit and Neonatal Intensive Care Unit (SCBU and NICU)
11. Laboratory, Radiology Department, Physiotherapy Unit, Indoor and Outdoor Pharmacies
RESOURCES
Consultants and other medical staff, Sisters and Nurses, Midwives, Attendants and other
staff in wards, clinics, delivery rooms and theatre.
Para Medical Services: Physiotherapist, Occupational and Speech Therapist, Radiographers
Patients and the caregivers are the most important resources for learning

30
ATTENDANCE RECORD
Date Signature certifying attendance
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

31
CHECKLIST
Clinical history and physical examination 1 2 3 4 5
1 Presentation of an obstetric history
Designation
Date
2 Presentation of a gynaecological history
Designation
Date
3 obstetric examination Presentation
Designation
Date
4 Gynaecological examination presentation
Designation
Date
5 Perform and present findings of obstetric abdominal examination
Designation
Date
6 Perform and present findings of vaginal and speculum
examinations in a gynaecological patient
Designation
Date
Tasks to be done under supervision 1 2 3 4 5
1. Insertion and removal of a vaginal ring pessary
Designation
Date
2. Prepare and manage a patient in labour
Designation
Date
3. Inspection of the placenta after delivery
Designation
Date
4. Setting up of a blood transfusion
Designation
Date
5. Writing of investigation forms
Designation
Date
6. Perform and repair episiotomies
Designation
Date
7. Obtain a high vaginal swab for culture
Designation
Date
8. Assist Breech delivery
Designation
Date

32
9. Assist Caesarean section
Designation
Date
10. Theatre attendance at routine gynaecology lists
Designation
Date
11. Urine ward test for sugar, albumin
Designation
Date
12. Post op monitoring of a gynaecology patient after major
surgery
Designation
Date
13. Writing of diagnosis cards
Designation
Date
Activities to be observed 1 2 3 4 5
1 Insertion of IUCD
Designation
Date
2 Resuscitation of a patient in shock
Designation
Date
3 Vacuum extraction
Designation
Date
4 Low Forceps delivery
Designation
Date
5 Obstetric abdominal US scanning
Designation
Date
6 Trans vaginal ultrasound scanning
Designation
Date
* First row of each item to be initialed by VOG / SR / SHO / HO / Nurse or Midwife

I hereby certify that the candidates attendance and performance has been satisfactory during
the period of training.

Signature of supervising VOG

Name of supervising VOG

Date: .
33