Iraqi Board Family Medicine cheat sheet

Four core principles of family medicine (WONCA): first contact/accessibility, continuity, comprehensiveness, and coordination with community orientation.

The patient-centred clinical method has six components: exploring both disease and illness experience, understanding the whole person, finding common ground, incorporating prevention and health promotion, enhancing the doctor-patient relationship, and being realistic.

Continuity has three types: informational (shared records), longitudinal (same clinician over time), and interpersonal (sustained trust relationship).

Primary care attributes associated with better outcomes (Starfield's four): first-contact access, longitudinality, comprehensiveness, and coordination.

The consultation model by Pendleton lists seven tasks, including understanding the patient's problem, agreeing on management, and using time and resources appropriately.

Family systems: genogram symbols - square = male, circle = female, horizontal line = marriage, vertical = descent, crossed symbol = deceased, double line = consanguineous marriage.

Referral decision rule: refer when diagnosis is uncertain after reasonable workup, management exceeds primary care resources, or a procedure requires specialist skill or facility.

Gatekeeping: the family physician as first contact filters access to secondary care; evidence shows stronger primary care orientation is associated with lower overall health system costs and better population outcomes.

Hypertension diagnosis: office BP ≥140/90 mmHg on two occasions; ambulatory/home readings ≥135/85 mmHg. Stage 2 = ≥160/100 mmHg; start two-drug therapy if ≥20/10 mmHg above target.

Type 2 diabetes diagnostic criteria: fasting plasma glucose ≥7.0 mmol/L (126 mg/dL), 2-hour OGTT ≥11.1 mmol/L (200 mg/dL), HbA1c ≥6.5% (48 mmol/mol), or random ≥11.1 with symptoms; repeat to confirm unless unequivocal.

Metformin is first-line for type 2 diabetes unless eGFR <30 mL/min/1.73m²; SGLT2 inhibitors or GLP-1 receptor agonists are preferred when ASCVD, heart failure, or CKD coexist.

Acute coronary syndrome: aspirin 300 mg chewed plus P2Y12 inhibitor and anticoagulation; STEMI requires reperfusion (PCI within 120 min of first medical contact) - do not delay transfer for thrombolysis if PCI is timely.

Heart failure with reduced EF: four pillars - ACE inhibitor/ARB or ARNI, beta-blocker, MRA, and SGLT2 inhibitor - each reduces mortality.

COPD: diagnosis confirmed by post-bronchodilator FEV1/FVC <0.70; GOLD ABE groups guide initial inhaled therapy; smoking cessation is the only intervention that slows decline.

Thyroid: primary hypothyroidism shows high TSH with low free T4; subclinical hypothyroidism shows high TSH with normal free T4 - treat if TSH >10 mIU/L or symptomatic.

Anemia classification by MCV: microcytic (<80 fL) - iron deficiency, thalassemia, chronic disease; normocytic (80-100 fL) - acute blood loss, renal disease; macrocytic (>100 fL) - B12/folate deficiency, alcohol, hypothyroidism.

Growth monitoring: plot weight-for-age, length/height-for-age, and weight-for-length/BMI on WHO charts; crossing two major centile lines downward signals faltering growth.

Developmental milestones: social smile 6 weeks; sits unsupported 6-8 months; walks 12-15 months; two-word phrases 18-24 months; three-word sentences by 3 years.

Acute otitis media: 80% resolve spontaneously; immediate antibiotics for children <6 months, severe symptoms, or bilateral infection in <2 years; amoxicillin first-line.

Bronchiolitis: supportive care only - oxygen if SpO2 <90-92%, hydration; no routine bronchodilators, steroids, or antibiotics. Most common pathogen is respiratory syncytial virus.

Kawasaki disease: fever ≥5 days plus 4 of 5 criteria (conjunctivitis, mucosal changes, rash, extremity changes, cervical lymphadenopathy); treat with IVIG 2 g/kg plus aspirin to prevent coronary aneurysms.

Dehydration in gastroenteritis: use ORS 50 mL/kg for mild (3-5%) and 100 mL/kg for moderate (5-10%) over 4 hours; do not use routine antiemetics or antibiotics.

Neonatal jaundice: pathological if onset <24 hours, bilirubin rising >5 mg/dL/day, or conjugated fraction elevated; treat with phototherapy per age-hour nomogram.

Immunization schedule principle: live vaccines (MMR, varicella, BCG, oral polio) are contraindicated in significant immunosuppression and pregnancy; inactivated vaccines are safe.

Estimated date of delivery: Naegele's rule - first day of last menstrual period + 280 days (or +9 months +7 days).

Antenatal visit schedule (WHO 2016): eight contacts - first before 12 weeks, then at 20, 26, 30, 34, 36, 38, and 40 weeks.

Folic acid 400 micrograms daily from at least 1 month before conception to 12 weeks; 5 mg daily if previous neural tube defect, diabetes, obesity, or antiepileptic use.

Rhesus prophylaxis: anti-D immunoglobulin at 28 weeks and within 72 hours of delivery if the baby is Rh-positive; also after miscarriage, ectopic, or invasive procedures.

Pre-eclampsia: BP ≥140/90 after 20 weeks plus proteinuria or maternal organ dysfunction; delivery is the definitive treatment; give magnesium sulfate for eclampsia prophylaxis in severe disease.

Postpartum hemorrhage: primary if within 24 hours; uterine atony causes ~70%; manage with uterine massage, oxytocin, then ergometrine/carboprost/misoprostol, then tranexamic acid 1 g IV within 3 hours.

Cervical screening: start at age 21-25 depending on guideline; repeat every 3 years with cytology or every 5 years with HPV testing; exit at 65 if adequate prior negative screening.

Emergency contraception: levonorgestrel 1.5 mg within 72 hours (best within 24 hours); ulipristal acetate 30 mg within 120 hours; copper IUD within 5 days is the most effective option.

Ottawa ankle rule: X-ray indicated if pain in malleolar zone plus bone tenderness at posterior edge of lateral or medial malleolus or inability to bear weight four steps.

Ottawa knee rule: X-ray if age ≥55, isolated patellar tenderness, fibular head tenderness, inability to flex to 90 degrees, or inability to bear weight.

Acute wound management: irrigate with normal saline under pressure, debride, close within 6-8 hours (up to 24 hours on face), and update tetanus prophylaxis.

Appendicitis: Alvarado score components - migration of pain (1), anorexia (1), nausea/vomiting (1), right lower quadrant tenderness (2), rebound tenderness (1), fever (1), leukocytosis (2).

Hernia: inguinal hernia in adults is repaired electively; strangulation features include sudden severe pain, irreducible mass, and systemic signs - require emergency surgery.

Low back pain red flags: age >50 with new pain, weight loss, night pain, fever, neurological deficit, bowel/bladder dysfunction, history of cancer, or trauma.

Fracture healing: immobilize and check neurovascular status before and after; open fractures need antibiotics and surgical debridement within 6 hours.

Breast lump: triple assessment - clinical examination, imaging (ultrasound if <40 years, mammogram if ≥40), and tissue sampling (FNA or core biopsy).

Major depressive disorder: ≥5 of 9 symptoms for ≥2 weeks, including depressed mood or anhedonia; screen with PHQ-9 (score ≥10 indicates moderate depression).

SSRIs are first-line for depression; onset of effect takes 2-4 weeks; continue for at least 6-12 months after remission to prevent relapse.

Serotonin syndrome triad: mental status change, autonomic instability, and neuromuscular hyperactivity (clonus, hyperreflexia); stop serotonergic drugs and give supportive care.

Bipolar disorder: manic episode requires elevated/irritable mood ≥1 week plus ≥3 of 7 symptoms (grandiosity, decreased sleep, pressured speech, flight of ideas, distractibility, increased activity, risky behavior).

Suicide risk assessment: ask directly about ideation, plan, intent, and access to means; high risk needs urgent psychiatric referral and removal of means.

Alcohol withdrawal: use CIWA-Ar to guide treatment; benzodiazepines are first-line; give thiamine before glucose to prevent Wernicke's encephalopathy.

Schizophrenia: positive symptoms (delusions, hallucinations) and negative symptoms (flat affect, avolition); antipsychotics are first-line; monitor for metabolic syndrome.

Panic attack: abrupt surge of intense fear peaking within minutes with ≥4 of 13 symptoms (palpitations, sweating, trembling, dyspnea, chest pain, paresthesia, fear of dying).

Levels of prevention: primordial (prevent risk factor emergence), primary (prevent disease before onset), secondary (early detection and treatment), tertiary (limit disability/rehabilitation), quaternary (avoid overmedicalization).

Herd immunity threshold = 1 - 1/R0; for measles R0 ≈ 12-18, requiring ~92-95% coverage.

Incidence measures new cases in a population at risk per unit time; prevalence measures all existing cases at a point (point) or over a period.

Relationship: prevalence ≈ incidence × average duration of disease (when disease is in steady state).

Sensitivity = TP/(TP+FN); specificity = TN/(TN+FP); positive predictive value depends on prevalence.

Screening test criteria (WHO): important health problem, accepted treatment, recognizable latent stage, suitable test, cost-effective, and continued case-finding.

Attack rate = number of new cases during an outbreak ÷ population at risk × 100; used in food-borne outbreak investigations.

Crude birth rate = live births in a year ÷ mid-year population × 1000; infant mortality rate = deaths under 1 year ÷ live births × 1000.

Study designs: cohort measures incidence and relative risk; case-control measures odds ratio; cross-sectional measures prevalence; RCT measures efficacy with randomization to control confounding.

Relative risk = incidence in exposed ÷ incidence in unexposed; odds ratio approximates RR when disease is rare (<10%).

Attributable risk = incidence in exposed − incidence in unexposed; population attributable fraction = (prevalence exposed × (RR−1)) ÷ (1 + prevalence exposed × (RR−1)).

Confounding: a variable associated with both exposure and outcome but not on the causal pathway; randomization, restriction, matching, or statistical adjustment controls it.

Bias types: selection bias (Berkson's, healthy worker), information bias (recall, interviewer), and confounding; each needs a different mitigation.

Diagnostic test likelihood ratios: positive LR = sensitivity ÷ (1 − specificity); negative LR = (1 − sensitivity) ÷ specificity.

Sample size for a proportion: n = Z² × p(1 − p) ÷ d²; for 95% confidence, Z = 1.96.

Confidence interval interpretation: 95% CI means that 95% of similarly constructed intervals contain the true parameter - not that there is a 95% probability the parameter is in this interval.

Primary prevention examples: immunization, smoking cessation, seatbelt use, and fluoridation. Secondary prevention examples: mammography, Pap smear, and colorectal cancer screening.

USPSTF Grade A/B recommendations are offered; Grade C is selective; Grade D is discouraged; Grade I has insufficient evidence.

Colorectal cancer screening: start at age 45-50; options include colonoscopy every 10 years, FIT annually, or CT colonography every 5 years.

Lung cancer screening: annual low-dose CT for adults aged 50-80 with ≥20 pack-year smoking history who currently smoke or quit within 15 years.

Tetanus-diphtheria booster every 10 years; Tdap in every pregnancy at 27-36 weeks; annual influenza vaccine for all ≥6 months.

Osteoporosis screening: DXA for women ≥65 and men ≥70; earlier if risk factors; T-score ≤ −2.5 defines osteoporosis.

Cardiovascular risk: use validated tools (e.g., ASCVD Pooled Cohort Equations or SCORE2) to guide statin initiation; statins reduce major vascular events by ~25% per 1 mmol/L LDL reduction.

Hepatitis B vaccination: three doses at 0, 1, and 6 months; post-vaccination serology for healthcare workers (anti-HBs ≥10 mIU/mL indicates protection).

Ottawa Charter (1986) five action areas: build healthy public policy, create supportive environments, strengthen community action, develop personal skills, and reorient health services.

Transtheoretical model stages: precontemplation, contemplation, preparation, action, maintenance, and relapse; interventions are matched to stage.

Five A's for smoking cessation: Ask, Advise, Assess, Assist, Arrange; brief advice alone increases quit rates.

Screening criteria (Wilson-Jungner): condition must be important, have a latent stage, suitable test, accepted treatment, and agreed policy on whom to treat.

Lead-time bias inflates apparent survival in screened populations without changing mortality; mortality is the preferred outcome in screening trials.

Overdiagnosis: detection of disease that would never cause symptoms or death; it leads to unnecessary treatment and is a key harm of screening.

Number needed to screen = 1 ÷ (absolute mortality reduction attributable to screening); useful for communicating benefit.

Motivational interviewing core principles: express empathy, develop discrepancy, roll with resistance, and support self-efficacy.

ABCDE approach: Airway with cervical spine protection, Breathing, Circulation with hemorrhage control, Disability (GCS, pupils), Exposure with temperature control.

Anaphylaxis: IM adrenaline 0.5 mg (0.5 mL of 1:1000) into the anterolateral thigh; repeat every 5 minutes if needed; adjuncts include oxygen, IV fluids, and antihistamines.

Acute asthma: oxygen to keep SpO2 94-98%, salbutamol nebulizers, ipratropium, systemic corticosteroids; add magnesium sulfate for severe or life-threatening attacks.

Sepsis: recognize with qSOFA (RR ≥22, altered mentation, SBP ≤100); give broad-spectrum antibiotics within 1 hour and 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.

Stroke: activate stroke pathway; non-contrast CT to exclude hemorrhage; IV thrombolysis within 4.5 hours of onset; thrombectomy up to 24 hours in selected patients.

Hypoglycemia: if conscious, 15-20 g oral glucose and recheck in 15 minutes; if unconscious, IV glucose or IM glucagon.

Cardiac arrest: high-quality chest compressions at 100-120/min, depth 5-6 cm, ratio 30:2, minimize interruptions; defibrillate shockable rhythms immediately.

Poisoning: activated charcoal within 1 hour if airway protected and no contraindication; specific antidotes include naloxone (opioids), N-acetylcysteine (paracetamol), and flumazenil (benzodiazepines - use with caution).

Comprehensive geriatric assessment domains: medical, functional, psychological, social, and environmental; it improves outcomes when linked to intervention.

Frailty: Fried phenotype uses weight loss, exhaustion, low activity, slow gait, and weakness; ≥3 criteria indicate frailty.

Beers criteria list potentially inappropriate medications in older adults; examples include benzodiazepines, anticholinergics, and long-acting sulfonylureas.

Polypharmacy: ≥5 medications; STOPP/START criteria identify inappropriate prescribing and omissions in older adults.

Falls: assess gait, vision, medications, home hazards, and orthostatic BP; multifactorial intervention reduces falls.

Delirium: acute onset, fluctuating course, inattention, and altered consciousness; use the 4AT or CAM; treat the underlying cause and avoid restraints.

Palliative care WHO definition: improves quality of life through prevention and relief of suffering by early identification and impeccable assessment and treatment of pain and other problems - physical, psychosocial, and spiritual.

Opioid step ladder (WHO): mild pain - non-opioid; moderate - weak opioid (codeine, tramadol); severe - strong opioid (morphine); use laxatives and antiemetics prophylactically.

Four principles of biomedical ethics: autonomy (respect patient choice), beneficence (act for benefit), non-maleficence (avoid harm), and justice (fair distribution).

Informed consent elements: capacity, adequate disclosure of risks/benefits/alternatives, comprehension, and voluntariness.

Confidentiality exceptions: patient consent, statutory reporting (notifiable diseases, child abuse), serious risk to others, and court order.

Capacity assessment: patient can understand, retain, weigh, and communicate a decision; capacity is decision-specific and presumed unless evidence otherwise.

Breaking bad news - SPIKES: Setting, Perception, Invitation, Knowledge, Empathy, Strategy and Summary.

Consent in minors: assess Gillick competence for under-16s; parental consent needed otherwise; emergency treatment may proceed under necessity.

Advance directives and DNACPR: respect patient autonomy; discuss with patient and family; document clearly and review regularly.

Professional boundaries: avoid dual relationships, declare conflicts of interest, and follow duty of candour after adverse events.

Research question format - PICO: Population, Intervention, Comparator, Outcome; use FINER criteria (Feasible, Interesting, Novel, Ethical, Relevant) to refine.

Randomization reduces selection bias; allocation concealment prevents foreknowledge of assignment; blinding reduces performance and detection bias.

Sample size depends on effect size, variance, alpha (usually 0.05), power (usually 80%), and dropout rate; larger effect size requires smaller sample.

Intention-to-treat analysis includes all randomized participants in their assigned groups; per-protocol analysis risks bias from dropouts.

Validity types: internal (does the study answer the question in its own sample) and external (generalizability); threats include confounding, bias, and chance.

Qualitative methods: interviews, focus groups, and observation; analyze with thematic analysis or grounded theory; sampling is purposive, not random.

Ethical approval: research ethics committee review; informed consent, confidentiality, and data protection must be documented.

Reporting guidelines: CONSORT for RCTs, STROBE for observational studies, PRISMA for systematic reviews, and STARD for diagnostic accuracy.

EBM five steps: ask a focused question, acquire evidence, appraise critically, apply to the patient, and assess performance.

Levels of evidence: systematic reviews/meta-analyses of RCTs at the top; then RCTs; then cohort; then case-control; then case series; then expert opinion.

Critical appraisal of therapy: was the study randomized and blinded? Was follow-up complete? Were groups similar at baseline? What is the effect size (RRR, ARR, NNT)?

Number needed to treat = 1 ÷ absolute risk reduction; number needed to harm = 1 ÷ absolute risk increase.

Publication bias: funnel plot asymmetry suggests small negative studies are missing; search trial registries and grey literature.

GRADE rates quality of evidence as high, moderate, low, or very low, based on risk of bias, inconsistency, indirectness, imprecision, and publication bias.

Learning theories: Kolb's experiential cycle (concrete experience, reflective observation, abstract conceptualization, active experimentation); Bloom's taxonomy (knowledge, skills, attitudes).

Miller's pyramid of clinical competence: knows, knows how, shows how, and does; assessment should match the level (MCQ for knows, OSCE for shows how, workplace-based for does).