Adult Medicine (Ambulatory Internal Medicine)
This domain tests internal medicine as it actually presents in a health-centre clinic: long-term condition control, rational prescribing, and knowing when a primary-care problem needs referral. OEFM items reward guideline-anchored thresholds and penalise decisions made on a single reading.
Core rules
- Hypertension: confirm on repeated readings over at least two visits, or with home/ambulatory monitoring. Treat to <140/90, and <130/80 in diabetes or CKD if tolerated. First line is an ACE inhibitor/ARB, a calcium-channel blocker, or a thiazide-like diuretic; never combine an ACEi with an ARB.
- Type 2 diabetes: HbA1c target <7% for most. Metformin is first line - do not initiate below eGFR 45, reduce the dose at eGFR 30-44, stop below 30. Add an SGLT2 inhibitor or GLP-1 receptor agonist early when there is ASCVD, heart failure, CKD with albuminuria, or obesity.
- Microcytic anaemia: check ferritin before giving iron. Haemoglobinopathies are common in Oman, so persistent microcytosis with a normal or high ferritin warrants haemoglobin electrophoresis.
- Recheck creatinine and potassium 1-2 weeks after starting or up-titrating an ACEi/ARB; a rise of up to 30% is acceptable.
Worked example
A 52-year-old with BMI 32 has BP 152/94 on two visits, HbA1c 7.8%, eGFR 55 and urine albumin-creatinine ratio 45 mg/mmol. Reasoning: confirmed hypertension plus albuminuric CKD plus diabetes means a renin-angiotensin blocker is preferred for renal protection over a beta-blocker; metformin continues at reduced dose; an SGLT2 inhibitor adds renal and cardiovascular benefit. Book renal function at two weeks and titrate the ACEi/ARB to maximum tolerated dose.
Traps that cost marks
Treating white-coat elevation; missing a secondary cause in a young or resistant patient; prescribing an NSAID alongside an ACEi and a diuretic; escalating to insulin before addressing adherence, diet and metformin.