Medicine: Clinical Reasoning and Safe Practice
The Medicine domain of the MDCN Assessment evaluates whether a foreign-trained doctor can apply Nigerian-standard clinical reasoning to common presentations, recognise emergencies, and manage patients safely within local resources. Questions often use short vignettes that require you to prioritise History, Examination, Investigation, and Management (HEIM) in the right order.
Core rules
- Start with ABCDE for any acutely unwell patient; do not take a lengthy history before addressing airway, breathing, circulation, disability, and exposure.
- In Nigeria, fever is not synonymous with malaria. For a stable patient, confirm with a malaria rapid diagnostic test (RDT) or microscopy before starting artemisinin-based combination therapy. Treat severe malaria immediately while confirming.
- Common high-yield conditions include malaria, hypertension and stroke, diabetes and hypoglycaemia, tuberculosis, HIV, meningitis, heart failure, asthma/COPD, gastroenteritis, peptic ulcer disease, and anaemia.
- Check pregnancy status and renal/hepatic function before prescribing, and adjust doses in renal impairment.
- Notify epidemic-prone diseases such as cholera, Lassa fever, measles, and meningitis to the local health authority.
Worked example
A 32-year-old man presents with 3 days of fever, headache, and vomiting. He is drowsy but protecting his airway; temperature is 39°C and neck stiffness is present. Reasoning: this is possible meningitis, not just malaria. After ABCDE and a glucose check, start empiric ceftriaxone and perform lumbar puncture if there is no contraindication such as focal neurological deficit, papilloedema, or coagulopathy. Send blood for malaria RDT and culture. Do not delay antibiotics for the lumbar puncture.
Traps that cost marks
Treating every fever as malaria; missing hypoglycaemia in a drowsy patient; prescribing NSAIDs in renal impairment; forgetting to ask about pregnancy; failing to notify a notifiable disease.