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Essential Diseases for MBBS Interns

1. INTERNAL MEDICINE / GENERAL MEDICINE

Cardiovascular

Respiratory

Gastroenterology

Endocrine & Metabolic

Nephrology

Neurology

Infections (High Yield in India)

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2. GENERAL SURGERY

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3. OBSTETRICS & GYNAECOLOGY

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4. PAEDIATRICS

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5. ORTHOPAEDICS

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6. ENT

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7. DERMATOLOGY

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8. PSYCHIATRY

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9. OPHTHALMOLOGY

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10. EMERGENCY / HIGH YIELD ACROSS ALL POSTINGS

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Tips for the Internship Year

1. Prioritise common presentations - fever, breathlessness, chest pain, altered consciousness, and abdominal pain are universal.
2. Know your investigations - CBC, LFT, RFT, electrolytes, ABG, ECG interpretation are daily tools.
3. Drug doses matter - Know doses for paracetamol, ceftriaxone, amoxicillin, metformin, furosemide, amlodipine, metoprolol, and insulin.
4. Procedural skills - IV cannulation, IM/SC injections, catheterisation, nasogastric tube insertion, ABG sampling, suturing.
5. Emergency protocols - BLS/ACLS, sepsis bundles, obstetric emergencies.
6. Communication - Consent, breaking bad news, discharge counselling.

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Latest Clinical Guidelines for MBBS Interns (2023-2026)

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MEDICINE POSTING

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1. Hypertension

• Hypertension defined as BP ≥130/80 mmHg (unchanged from 2017 ACC/AHA)
• First-line agents: ACE inhibitor/ARB, thiazide, or CCB (all equivalent)
• Lifestyle modification first for Stage 1 (130-139/80-89) without high CVD risk
• Target BP <130/80 in most adults; <140/90 acceptable in older/frail patients
• ICMR STW (India): Available at icmr.gov.in/standard-treatment-workflows-stws - Indian staging and drug cost considerations

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2. Diabetes Mellitus Type 2

• HbA1c target: <7% for most patients, <8% for older/high-risk
• First-line: Metformin + lifestyle; add GLP-1 RA or SGLT-2i if ASCVD/HF/CKD present
• SGLT-2 inhibitors (empagliflozin, dapagliflozin) recommended if HFrEF or CKD
• GLP-1 agonists (semaglutide, liraglutide) preferred if ASCVD or obesity
• ICMR STW India: Metformin 500-1000 mg BD as cornerstone; emphasis on HbA1c + creatinine + urine ACR monitoring
• DKA: Fluid 1L NS in 1st hour, insulin 0.1 unit/kg/hr, K+ replacement once K>3.3

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3. Community-Acquired Pneumonia (CAP)

• CURB-65 for severity (0-1: outpatient, 2: hospital, 3+: ICU consideration)
• Outpatient: Amoxicillin 1g TDS (preferred over azithromycin monotherapy) or doxycycline 100mg BD
• Inpatient non-severe: Beta-lactam + macrolide, or respiratory fluoroquinolone
• Severe/ICU: Beta-lactam + macrolide + antipseudomonal cover if risk factors
• 5-day antibiotic course adequate in most patients (shorter is now preferred)
• French 2025 update also recommends de-escalation within 48-72 hrs once cultures available [PMID: 40037948]

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4. Sepsis

• Adults: SSC 2021 guidelines still in force; Hour-1 Bundle: blood cultures x2, lactate, IV antibiotics, 30 mL/kg crystalloid if hypotensive
• qSOFA ≥2 for screening (sensitivity-focused); SOFA ≥2 for organ dysfunction
• Antibiotics within 1 hour of recognition
• Norepinephrine as first-choice vasopressor
• Hydrocortisone 200 mg/day in septic shock not responding to vasopressors
• German S3 Guideline 2025 [PMID: 40824313] and ESICM Circulatory Shock Guidelines 2025 [PMID: 41236566] available for reference

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5. Atrial Fibrillation

• Rate control target: resting HR <110 bpm (lenient) acceptable for stable patients
• Anticoagulation: DOACs (apixaban, rivaroxaban) preferred over warfarin for non-valvular AF
• CHA2DS2-VASc score: anticoagulate men ≥2, women ≥3
• Rhythm control: benefit in early AF/symptomatic patients (EAST-AFNET evidence incorporated)

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6. Acute Ischaemic Stroke

• IV alteplase (tPA) still standard within 4.5 hours of onset
• Mechanical thrombectomy: up to 24 hours in selected patients (DWI-ASPECTS criteria)
• BP <185/110 before thrombolysis; maintain <180/105 for 24 hrs after
• Dual antiplatelet (aspirin + clopidogrel) for 21 days after minor stroke/TIA (POINT trial)
• Statin therapy initiated early

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7. Heart Failure

• "Fantastic Four" drugs for HFrEF (EF <40%):
  1. ACE-i/ARB-neprilysin inhibitor (sacubitril-valsartan preferred over ACEi)
  2. Beta-blocker (carvedilol, bisoprolol, metoprolol succinate)
  3. Mineralocorticoid receptor antagonist (spironolactone/eplerenone)
  4. SGLT-2 inhibitor (dapagliflozin/empagliflozin) - this is the major 2022 addition
• Loop diuretics for congestion relief only (not survival benefit)
• HFpEF (EF ≥50%): SGLT-2i now recommended, no proven mortality benefit from RAS agents

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8. Tuberculosis (India-Specific)

• Drug-Susceptible TB: 2HRZE/4HR (unchanged)
• Preferred DS-TB regimen: Isoniazid + Rifampicin + Pyrazinamide + Ethambutol x 2 months, then HR x 4 months
• Drug-Resistant TB (2024 update): BPaLM regimen (Bedaquiline + Pretomanid + Linezolid + Moxifloxacin) for 26 weeks - injection-free fully oral
  • Bdq: 400 mg daily x 2 weeks, then 200 mg TIW
  • Pretomanid: 200 mg daily
  • Linezolid: 600 mg daily
  • Moxifloxacin: 400 mg daily
• Active screening for TB-diabetes, TB-HIV co-infection
• India TB Report 2024: Treatment success rate DS-TB 85% (public), 87% (private)

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9. Malaria

• Uncomplicated P. falciparum: Artemisinin-based Combination Therapy (ACT) - Artemether-Lumefantrine (preferred in India)
• Severe malaria: IV/IM artesunate (replaces quinine as first-line)
• P. vivax: Chloroquine 25 mg/kg over 3 days + Primaquine 0.25 mg/kg/day x 14 days (G6PD screen first)
• P. vivax radical cure in pregnancy: Chloroquine only (no primaquine); defer radical cure to post-delivery
• RDT diagnosis acceptable where microscopy unavailable
• Chemoprevention: SMC (Seasonal Malaria Chemoprevention) for high-burden areas

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SURGERY POSTING

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10. Acute Appendicitis

• Alvarado/MANTRELS score: ≥7 = high probability, proceed to surgery
• CT abdomen: gold standard imaging (if US inconclusive)
• Laparoscopic appendicectomy: preferred approach
• Uncomplicated appendicitis: antibiotic-first approach (amoxicillin-clavulanate) shown non-inferior in selected patients; however, surgery remains standard in India
• Prophylactic antibiotics: cefazolin single dose pre-op; extend to 24 hrs if perforated

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11. Acute Abdomen / Peritonitis

• Erect CXR: free air under diaphragm = perforated hollow viscus
• Resuscitation: IV fluids, NGT, catheter, blood cultures, antibiotics (piperacillin-tazobactam or cefuroxime + metronidazole)
• Emergency laparotomy / laparoscopy: definitive treatment
• Enhanced Recovery After Surgery (ERAS) protocols: early feeding, DVT prophylaxis, minimise opioids

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12. Acute Pancreatitis

• Revised Atlanta Classification: mild/moderately severe/severe
• Key principle: Aggressive IV fluid resuscitation with Ringer's Lactate (preferred over NS, reduces SIRS)
• Early oral feeding when tolerated (not NPO unless vomiting/ileus)
• Antibiotics: NOT routinely given; only for confirmed infected necrosis
• ERCP within 24 hrs if concurrent cholangitis

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13. GI Bleed

• Rockall score pre-endoscopy and post-endoscopy
• IV PPI (omeprazole 80 mg bolus then 8 mg/hr) before endoscopy
• Endoscopy within 24 hours (12 hrs if hemodynamically unstable)
• Variceal bleed: terlipressin + ceftriaxone + urgent endoscopy + banding/sclerotherapy
• Transfusion target Hb ≥7 g/dL (restrictive strategy superior - TRICC trial)

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OBG POSTING

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14. Pre-eclampsia / Hypertension in Pregnancy

• Diagnosis: BP ≥140/90 on two occasions ≥4 hrs apart after 20 weeks
• First-line antihypertensives in pregnancy: Labetalol IV, Hydralazine IV, Nifedipine oral (all acceptable)
• Severe HTN (≥160/110): treat within 30-60 minutes (new urgency threshold)
• Seizure prevention/treatment: Magnesium Sulphate - loading dose 4g IV over 15-20 min, then 1g/hr infusion
• Aspirin 75-150 mg/day from 12-16 weeks in high-risk patients (prior pre-eclampsia, CKD, diabetes)
• Definitive treatment: delivery

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15. Postpartum Haemorrhage (PPH)

• Definition: blood loss ≥500 mL after vaginal delivery, ≥1000 mL after caesarean
• First-line uterotonic: Oxytocin 10 IU IM immediately after delivery of baby (active management of 3rd stage)
• If oxytocin fails: Ergometrine, Carboprost, Misoprostol 800 mcg SL
• Tranexamic acid 1g IV within 3 hours of PPH (WOMAN trial evidence) - now standard
• Non-pneumatic anti-shock garment (NASG) in resource-limited settings
• Surgical: B-Lynch suture, uterine artery ligation, hysterectomy as last resort

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16. Normal Labour Management

• Partograph use mandated by WHO and Indian MoHFW
• Active phase: cervical dilatation ≥1 cm/hour
• Alert line and action line on partograph: cross action line = intervention needed
• CTG category I (normal), II (indeterminate), III (abnormal - emergency delivery)
• Second stage: push with contractions; instrumental delivery if arrest >1 hr (nullipara) or >30 min (multipara)

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PAEDIATRICS POSTING

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17. Childhood Pneumonia

• Age-specific respiratory rate thresholds:
  • <2 months: ≥60 breaths/min
  • 2-12 months: ≥50 breaths/min
  • 1-5 years: ≥40 breaths/min
• Outpatient: Amoxicillin 40-45 mg/kg/day BD x 5 days
• Severe: IV Ampicillin + Gentamicin (or Benzylpenicillin)
• Oxygen target SpO2 >90%

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18. Acute Diarrhoea / Dehydration

• ORS: 75 mEq/L sodium, 75 mmol/L glucose (reduced osmolarity - superior to standard ORS)
• Zinc supplementation: 20 mg/day x 10-14 days (children >6 months) - reduces severity/duration
• Antibiotics: NOT routine; use for cholera (azithromycin), bloody diarrhoea (ciprofloxacin/ceftriaxone)
• Breastfeeding should continue throughout

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19. Paediatric Sepsis

• Fluid resuscitation: 10-20 mL/kg NS or RL boluses, titrated to response (NOT the old 60 mL/kg blanket approach - FEAST trial changed this)
• Vasopressors (dopamine/norepinephrine) if fluid-unresponsive
• Broad-spectrum antibiotics within 1 hour
• Blood culture before antibiotics
• Glucose monitoring (avoid hypoglycaemia)

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20. Neonatal Jaundice

• Phototherapy thresholds are now based on: age in hours + gestational age + risk factors (nomogram-based)
• Universal bilirubin screening at 24-48 hrs recommended
• Exchange transfusion: if bilirubin exceeds exchange threshold (higher threshold than phototherapy)

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EMERGENCY POSTING

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21. Cardiac Arrest / BLS-ACLS

• Compression rate: 100-120/min, depth 5-6 cm
• Hands-only CPR acceptable for bystanders
• Defibrillation for shockable rhythms (VF/pVT): as soon as AED available
• Adrenaline 1 mg IV every 3-5 min for non-shockable rhythms; give after 3rd shock for shockable
• Amiodarone 300 mg IV for VF/pVT after 3rd shock
• Post-ROSC: targeted temperature management 32-36°C

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22. Anaphylaxis

• IM Adrenaline 0.5 mg (adult) / 0.3 mg (child) in anterolateral thigh - FIRST-LINE, no delay
• Lay flat + legs elevated (unless respiratory distress)
• IV fluids (1-2L NS) for hypotension
• Adrenaline can repeat every 5-15 minutes
• H1 antihistamines and corticosteroids are adjuncts, NOT first-line
• Observe minimum 4-6 hours for biphasic reaction

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QUICK REFERENCE TABLE - Guideline Sources

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Where to Access Guidelines (Free)

1. ICMR STWs (India): stw.icmr.org.in - free download of all Indian Standard Treatment Workflows
2. WHO Guidelines: who.int/publications - all WHO guidelines free access
3. NTEP (TB): tbcindia.mohfw.gov.in - India TB guidelines and reports
4. AHA/ACC: ahajournals.org - most practice guidelines are open access
5. IDSA/ATS: idsociety.org and thoracic.org - infectious disease and pulmonology
6. PubMed: pubmed.ncbi.nlm.nih.gov - search "[topic] guidelines 2024" with Practice Guideline filter

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