Internal Medicine
Internal Medicine is a major content block in the NMCLE. It tests whether you can take a common Nepali presentation - fever, breathlessness, chest pain, oedema, altered consciousness - and reach a safe first-line decision. Items favour conditions you will actually see: tuberculosis, COPD, rheumatic heart disease, dengue and scrub typhus, diabetes and its emergencies, stroke, and cirrhosis.
Core rules
- Fever: duration and exposure drive the workup. Enteric fever (blood culture in week 1), scrub typhus (eschar; doxycycline), dengue (NS1 in the first 5 days), malaria (thick and thin films) and pulmonary TB (sputum Xpert MTB/RIF) are the default differentials.
- Acute coronary syndrome: 12-lead ECG within 10 minutes; chew 300 mg aspirin at once; add a P2Y12 inhibitor and a statin; reperfuse - primary PCI if available within 120 minutes, otherwise thrombolysis.
- Stroke: non-contrast CT first to exclude haemorrhage; the thrombolysis window is 4.5 hours from onset.
- DKA: isotonic saline, insulin infusion 0.1 U/kg/h, and check potassium - if below 3.3 mmol/L, replace potassium before starting insulin.
- Ascites in cirrhosis: sodium restriction, spironolactone with furosemide, and paracentesis for tense or infected ascites.
Worked example
A 58-year-old smoker has two hours of crushing retrosternal pain, sweating, and ST elevation in V1–V4. This is an anterior STEMI. Give chewed aspirin, a P2Y12 inhibitor and a statin; arrange urgent reperfusion; give oxygen only if saturation is below 90%; monitor for ventricular arrhythmia in the first 24 hours.
Traps
- Labelling chest pain as gastritis without an ECG.
- Starting an insulin infusion in DKA before checking potassium.
- Transfusing a stable patient at haemoglobin 8 g/dL.
- Treating every fever as typhoid without cultures.