What an MBBS Student Should Know Before Attending a GP Clinic

1. History Taking (The Core Skill)

• Site - Where is it?
• Onset - When did it start? Sudden or gradual?
• Character - Dull, sharp, burning, colicky?
• Radiation - Does it spread anywhere?
• Associating features - Nausea, fever, vomiting, etc.?
• Time course - Constant, intermittent, getting better or worse?
• Exacerbating/relieving factors - What makes it better or worse?
• Severity - Score 1-10

2. Vital Signs - Know How to Measure and Interpret

3. Common Presentations You Will See Daily

Infectious / Febrile Illness

• Fever - viral URTI, typhoid, malaria, dengue, UTI
• Cough + cold - viral, bacterial pneumonia, TB (always think about TB in India)
• Diarrhea + vomiting - gastroenteritis, food poisoning

Chronic Disease Management (Very Common in GP)

• Hypertension - know the JNC/ESH staging, first-line drugs (amlodipine, losartan, atenolol)
• Type 2 Diabetes - know HbA1c targets, metformin as first-line, symptoms of hypoglycemia
• Asthma/COPD - know the difference, reliever vs controller inhalers

GI Complaints

• Gastritis/peptic ulcer - epigastric pain, H. pylori, PPI therapy
• Constipation, IBS

Musculoskeletal

• Back pain, knee pain, arthritis (OA vs RA)

Others

• Headache (tension, migraine, red flags for dangerous causes)
• Skin conditions (rashes, wound care, fungal infections)
• Anemia (iron deficiency is most common - pallor, fatigue, low Hb)

4. Basic Physical Examination Skills

General Examination (Always Do This First)

• Pallor (inner eyelids, palms), Icterus (eyes), Cyanosis (lips/fingers), Clubbing (fingers), Lymphadenopathy, Edema (ankles)
• These are called PICCLOE in some mnemonics

Cardiovascular

• Feel for apex beat, auscultate heart sounds (S1, S2 - know where to listen)
• JVP, peripheral pulses

Respiratory

• Inspection (chest shape, breathing pattern), Palpation (trachea, expansion), Percussion, Auscultation (breath sounds, crepitations, wheeze)

Abdomen

• Inspection, Auscultation (bowel sounds), Percussion, Palpation (tenderness, organomegaly - liver, spleen)

Neurological (Basics)

• Conscious level (GCS or AVPU), Pupils, Limb power and reflexes

5. Basic Pharmacology - Drugs You Will See Prescribed

6. Basic Investigations - How to Read & When to Order

• CBC (Complete Blood Count) - Hb, WBC, Platelets - interpret anemia, infection, thrombocytopenia
• RBS / FBS / HbA1c - diabetes screening and monitoring
• LFT, KFT - liver and kidney function
• TSH - thyroid
• ESR, CRP - inflammation markers

• Urine routine/microscopy - UTI (pus cells, bacteria), kidney disease (protein, casts)

• Rate, rhythm, P-Q-R-S-T - know normal sinus rhythm
• Recognize LBBB, ST elevation (MI), AF

• Chest X-ray: know normal anatomy, cardiomegaly, consolidation, pleural effusion
• Ultrasound abdomen: when to order it

7. Red Flag Symptoms - Know When to Refer

• Chest pain + sweating - possible MI (refer immediately, ECG)
• Sudden severe headache - subarachnoid hemorrhage ("thunderclap")
• Stroke symptoms - FAST (Face drooping, Arm weakness, Speech, Time to call)
• Breathlessness at rest / SpO2 <94% - urgent evaluation
• Unexplained weight loss + night sweats - malignancy or TB
• Blood in stool/vomit, black tarry stool - GI bleed
• High fever + neck stiffness + rash - meningitis
• Altered consciousness - admit, investigate urgently

8. Communication & Patient Interaction

• Introducing yourself ("I'm a medical student, may I take your history?")
• Using simple, non-technical language
• Active listening - don't interrupt, let the patient finish
• Explaining a diagnosis or plan clearly to the patient
• Being respectful of privacy and dignity

9. Practical Tips for Your Attachment

1. Carry a small pocket notebook - write down drugs you don't know, look them up after the session
2. Ask the GP to explain their reasoning - "Why did you choose this drug?" is a great learning question
3. Practice vitals on every patient - even if you already know how, speed and accuracy come with repetition
4. Read 1-2 common case summaries the night before - e.g., review hypertension management before a session in a diabetic/HTN clinic
5. Don't be afraid to say "I don't know" - just follow up with "I will find out"
6. Observe prescription writing - generic names, dose, duration, and instructions are all important
7. Mobile references - download Medscape or UpToDate (student access) for quick drug lookups

Recommended Books to Read During This Period

• Macleod's Clinical Examination - for history and examination skills (the gold standard)
• Davidson's Principles and Practice of Medicine - for common diseases
• Oxford Handbook of General Practice - quick reference for GP conditions
• Hutchison's Clinical Methods - another excellent clinical examination book
• KD Tripathi's Essentials of Medical Pharmacology - for Indian context pharmacology

Basic Drugs Every MBBS Student Should Know for GP Practice

GROUP 1 - Analgesics & Antipyretics

1. Paracetamol (Acetaminophen)

• Class: Non-opioid analgesic / antipyretic
• Mechanism: Inhibits prostaglandin synthesis centrally (exact mechanism debated); no significant peripheral anti-inflammatory effect
• Uses: Fever, mild-to-moderate pain (headache, myalgia, toothache)
• Dose: 500mg - 1g orally, every 4-6 hrs; Max 4g/day in adults
• Side Effects: Very safe at therapeutic doses
• Danger: Overdose causes hepatotoxicity (liver failure) - this is the #1 cause of acute liver failure in many countries
• Contraindication: Liver disease, alcoholism

2. Ibuprofen

• Class: NSAID (Non-Steroidal Anti-Inflammatory Drug)
• Mechanism: Inhibits COX-1 and COX-2 enzymes → reduces prostaglandins → reduces pain, fever, inflammation
• Uses: Pain, fever, dysmenorrhea, mild arthritis
• Dose: 400mg orally every 6-8 hrs, with food
• Side Effects: GI irritation/ulcers, renal impairment, fluid retention
• Contraindications: Peptic ulcer disease, renal failure, last trimester of pregnancy, aspirin-sensitive asthma

3. Diclofenac

• Class: NSAID
• Uses: Musculoskeletal pain, post-op pain (available as tablet, injection, gel)
• Dose: 50mg orally 2-3 times/day
• Key Point: Higher cardiovascular risk than ibuprofen; avoid in heart disease

GROUP 2 - Antibiotics (The Most Important Class in GP)

4. Amoxicillin

• Class: Aminopenicillin (Beta-lactam antibiotic)
• Mechanism: Inhibits bacterial cell wall synthesis (binds PBPs)
• Spectrum: Gram-positive + some Gram-negative (H. influenzae, E. coli)
• Uses: Throat infections (strep pharyngitis), otitis media, sinusitis, urinary tract infections, H. pylori (triple therapy)
• Dose: 500mg orally every 8 hrs (adults)
• Side Effects: Diarrhea, allergic rash, anaphylaxis
• Contraindication: Penicillin allergy

5. Amoxicillin + Clavulanate (Co-amoxiclav / Augmentin)

• Why it exists: Clavulanate inhibits beta-lactamase enzymes that destroy amoxicillin
• Uses: Skin/soft tissue infections, animal bites, complicated UTIs, sinusitis
• Dose: 625mg (500mg + 125mg) every 8 hrs
• Side Effect: More GI upset than amoxicillin alone

6. Azithromycin

• Class: Macrolide antibiotic
• Mechanism: Inhibits bacterial protein synthesis (binds 50S ribosome)
• Spectrum: Atypical organisms (Mycoplasma, Chlamydia, Legionella), Gram-positive, some Gram-negative
• Uses: Community-acquired pneumonia, atypical pneumonia, STIs (chlamydia), throat infections in penicillin-allergic patients
• Dose: 500mg once daily for 3-5 days (Z-pack)
• Side Effects: GI upset, QT prolongation (important!)
• Key Advantage: Once-daily dosing, good compliance

7. Ciprofloxacin

• Class: Fluoroquinolone antibiotic
• Mechanism: Inhibits DNA gyrase and topoisomerase IV (blocks DNA replication)
• Spectrum: Broad - excellent Gram-negative coverage
• Uses: UTIs, traveler's diarrhea, typhoid fever, respiratory infections
• Dose: 500mg orally every 12 hrs
• Side Effects: Tendonitis/tendon rupture, QT prolongation, photosensitivity, CNS effects (seizures at high doses)
• Contraindication: Children and adolescents (damages growing cartilage), pregnancy

8. Metronidazole

• Class: Nitroimidazole antibiotic/antiprotozoal
• Mechanism: Forms free radicals that damage bacterial/protozoal DNA
• Spectrum: Anaerobes, protozoa (Giardia, Entamoeba, Trichomonas)
• Uses: Amoebic dysentery, Giardiasis, bacterial vaginosis, dental infections, H. pylori (triple therapy), C. difficile
• Dose: 400-500mg orally every 8 hrs
• Side Effects: Metallic taste, nausea, peripheral neuropathy (with long use)
• Critical Interaction: Disulfiram-like reaction with alcohol - tell every patient to avoid alcohol completely

9. Doxycycline

• Class: Tetracycline antibiotic
• Mechanism: Inhibits protein synthesis (30S ribosome)
• Uses: Malaria prophylaxis, atypical pneumonia, Rickettsial infections, acne, STIs (chlamydia)
• Dose: 100mg orally once or twice daily
• Side Effects: Photosensitivity, GI irritation, esophageal ulceration (take with plenty of water, stay upright)
• Contraindication: Pregnancy, children under 8 years (stains developing teeth)

GROUP 3 - Antihypertensives

10. Amlodipine

• Class: Dihydropyridine Calcium Channel Blocker (CCB)
• Mechanism: Blocks L-type calcium channels in vascular smooth muscle → vasodilation → lowers BP
• Uses: Hypertension, stable angina
• Dose: 5-10mg orally once daily
• Side Effects: Pedal edema (ankle swelling), headache, flushing, palpitations
• Advantage: Once daily, well tolerated, safe in most patients

11. Losartan / Telmisartan

• Class: Angiotensin Receptor Blocker (ARB)
• Mechanism: Blocks AT1 receptors → prevents angiotensin II vasoconstriction → lowers BP
• Uses: Hypertension, diabetic nephropathy, heart failure
• Dose: Losartan 50mg once daily (up to 100mg)
• Side Effects: Hyperkalemia, renal impairment, dizziness
• Advantage over ACE inhibitors: No dry cough
• Contraindication: Pregnancy (teratogenic), bilateral renal artery stenosis

12. Enalapril / Ramipril (ACE Inhibitors)

• Class: ACE Inhibitor (ACEI)
• Mechanism: Blocks conversion of Angiotensin I → II; also prevents bradykinin breakdown
• Uses: Hypertension, heart failure, post-MI, diabetic nephropathy
• Dose: Enalapril 5-20mg once/twice daily
• Side Effects: Dry persistent cough (most common, due to bradykinin), hyperkalemia, angioedema (rare but dangerous)
• Contraindication: Pregnancy, angioedema history

13. Atenolol / Metoprolol (Beta-Blockers)

• Class: Beta-1 selective adrenergic blocker
• Mechanism: Blocks β1 receptors → reduces heart rate and cardiac output → lowers BP
• Uses: Hypertension, angina, post-MI, heart failure, arrhythmias, anxiety (off-label)
• Dose: Atenolol 50-100mg once daily
• Side Effects: Bradycardia, fatigue, cold extremities, erectile dysfunction, masking of hypoglycemia
• Contraindication: Asthma/COPD (can cause bronchospasm), heart block, cardiogenic shock

14. Hydrochlorothiazide (HCTZ)

• Class: Thiazide diuretic
• Mechanism: Inhibits Na-Cl cotransporter in distal tubule → natriuresis → reduces blood volume
• Uses: Hypertension (especially in combination), edema
• Dose: 12.5-25mg once daily
• Side Effects: Hypokalemia, hyperuricemia (can trigger gout), hyperglycemia, hyponatremia

GROUP 4 - Antidiabetics

15. Metformin

• Class: Biguanide
• Mechanism: Activates AMPK → reduces hepatic glucose output (gluconeogenesis); improves insulin sensitivity
• Uses: Type 2 Diabetes - first-line drug
• Dose: 500mg twice daily with meals, titrate to 1000mg twice daily
• Side Effects: GI upset (nausea, diarrhea) - give with food to minimize; Lactic acidosis (rare but serious)
• Contraindication: eGFR <30, contrast media procedures (hold temporarily), severe liver disease, alcoholism
• Advantage: No hypoglycemia as monotherapy, weight neutral or causes slight weight loss

16. Glimepiride / Glipizide (Sulfonylureas)

• Class: Sulfonylurea
• Mechanism: Closes ATP-sensitive K+ channels in beta cells → depolarization → insulin secretion (insulin secretagogue)
• Uses: Type 2 Diabetes (often added to metformin)
• Dose: Glimepiride 1-4mg once daily before breakfast
• Side Effects: Hypoglycemia (most important - warn patients), weight gain
• Contraindication: Type 1 diabetes, renal/hepatic failure

GROUP 5 - Acid-Related Disorders

17. Omeprazole / Pantoprazole (PPIs)

• Class: Proton Pump Inhibitor
• Mechanism: Irreversibly blocks H+/K+-ATPase pump in gastric parietal cells → profound, long-lasting acid suppression
• Uses: Peptic ulcer disease, GERD, H. pylori eradication (triple therapy), NSAID-induced gastropathy
• Dose: 20-40mg orally once daily before breakfast
• Side Effects: Headache, diarrhea, hypomagnesemia with long-term use, increased C. difficile risk
• Note: Duration of action much longer than half-life - once daily dosing is effective

18. Ranitidine / Famotidine (H2 Blockers)

• Class: H2 receptor antagonist
• Mechanism: Blocks H2 receptors on parietal cells → reduces acid secretion (less effective than PPIs for nocturnal acid)
• Uses: Mild GERD, peptic ulcer (less preferred now), OTC heartburn
• Dose: Famotidine 20-40mg at night

GROUP 6 - Antiallergy / Antihistamines

19. Cetirizine / Loratadine (2nd Gen Antihistamines)

• Class: H1 receptor antagonist (non-sedating)
• Mechanism: Blocks peripheral H1 receptors → reduces allergic symptoms
• Uses: Allergic rhinitis, urticaria (hives), allergic conjunctivitis
• Dose: Cetirizine 10mg once daily at night
• Advantage: Non-sedating (does not cross BBB well), once daily

20. Chlorpheniramine (1st Gen Antihistamine)

• Mechanism: Same, but crosses BBB → sedating
• Uses: Acute allergic reactions, common cold symptoms
• Side Effects: Sedation, dry mouth, urinary retention (anticholinergic), blurred vision
• Caution: Avoid in elderly (falls risk), BPH, glaucoma

GROUP 7 - Respiratory Drugs

21. Salbutamol (Albuterol)

• Class: Short-Acting Beta-2 Agonist (SABA) - Reliever inhaler
• Mechanism: Stimulates β2 receptors in bronchial smooth muscle → bronchodilation
• Uses: Acute bronchospasm (asthma attack, COPD exacerbation)
• Dose: 2 puffs (100mcg each) via inhaler as needed; Nebulization in severe attacks
• Side Effects: Tremor, tachycardia, hypokalemia (with high doses)
• Key Teaching Point: This is a reliever (rescue), NOT a preventer

22. Budesonide / Beclomethasone (Inhaled Corticosteroids - ICS)

• Class: Inhaled corticosteroid - Controller inhaler
• Mechanism: Reduces airway inflammation, reduces mucus secretion
• Uses: Persistent asthma (daily controller)
• Dose: 200-400mcg twice daily via inhaler
• Side Effects: Oral candidiasis (thrush) - tell patients to rinse mouth after use
• Key Teaching Point: This is a preventer/controller, not for acute attacks

GROUP 8 - Others You'll Commonly See

How to Study Each Drug (Quick Framework)

Drug Name
├── Class
├── Mechanism of action (MOA) - one sentence
├── Main indication(s)
├── Dose (adult, oral)
├── Major side effects (≤3)
└── Key contraindication / interaction

Most Important Side Effects to Never Forget