SYLLABUS

Cardiology
• Preventive Cardiology
• Coronary Heart Disease
• Acute Rheumatic Fever
• Rheumatic Heart Disease
• Valvular Heart disease
• Infective Endocarditis
• Dizziness/ Syncope and Palpitation
• Arrythmias
• Haemodynamic disturbances
• Hypotension and shock
• CPR, Basic Life Support,
• Advanced Cardiac Life Support
• Heart Failure
• Myocardiditis Cardiomyopathies
• Pericarditis
• Hypertension
Pulmonology
• Prevention of Respiratory diseases
• Cough, Haemoptysis, Dyspnoea
• Pneumonias, Lung abscess
• Bronchiectasis
• Bronchial Asthma
• COPD
• Pulmonary Tuberculosis
• Pleural Effusion
• Pneumothorax
• Lung Cancer
• Interstitial Lung disease and fibrosis
• DVT/ Pulmonary embolism
• Oxygen therapy
• Assisted ventilation
Medical Oncology Including Hematology
• Anemias
• Haemoglobinopathies
• Neutropenia, Neutropenic sepsis
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INTERMEDIATE MODULE
IN
MEDICINE & ALLIED
REQUIREMENTS FOR TRAINING & EXAMINATION

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THIS IS AN EVOLVING DOCUMENT
The College of Physicians and Surgeons Pakistan
would appreciate any criticism, suggestions, advice from the
readers and users of this document. Comments may be sent in
writing or by e-mail to the CPSP at:
DIRECTORATE OF NATIONAL RESIDENCY PROGRAM (DNRP)
College of Physicians and Surgeons Pakistan (CPSP)
7th Central Street, Defence Housing Authority, Karachi-75500.
[email protected]

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01 Introduction
03 Training and Examination
07 Assessment
25 Syllabus
CONTENTS
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The College was established in 1962 through an ordinance of
the Federal Government. The objectives and functions of the
College include: promotion of specialist practice by securing
improvement of teaching and training; arranging postgraduate
medical, surgical and other specialist training; holding and
conducting examinations for awarding College diplomas and
admission to the Fellowships of the College.
Since its inception, the College has taken great strides in
improving postgraduate medical and dental education in
Pakistan. Competency-based structured Residency Programs
have now been developed, along with criteria for accreditation
of training institutions, and for the appointment of supervisors
and examiners. The format of examinations has evolved over
the years to achieve greater objectivity and reliability in
methods of assessment. The recognition of the standards of
College qualifications nationally and internationally,
particularly of its Fellowship, has enormously increased the
number of trainees, and consequently the number of training
institutions and the supervisors. The rapid increase in
knowledge base of medical sciences and consequent
emergence of new subspecialties have gradually increased the
number of CPSP fellowship disciplines to seventy three.
After completing two years of core training during IMM, the
trainees are allowed to proceed to the advance phase of
FCPS training in the specific specialty of choice for 2-3 years.
However, it is mandatory to qualify IMM examination before
taking the FCPS-II exit examination. The work performed by the
trainee is to be recorded in the e-Iog book on daily basis. The
purpose of the e-Iog is to ensure that the entries are made on a
regular basis and to avoid belated and fabricated entries. It will
hence promote accuracy, authenticity and vigilance on the part
of trainees and the supervisors.
INTRODUCTION
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The average number of candidates taking CPSP examinations
each year around 23,000. The College conducts examinations
for FCPS I (11 groups of disciplines), IMM, FCPS II (73
disciplines), MCPS (22 disciplines), including MCPS in HPE and
MCPS in HCSM. A large number of Fellows and senior medical
teachers from within the country and overseas are involved
at various levels of examinations of the College. The College,
in its endeavor to decrease inter-rater variability and increase
fairness and transparency, is using TOACS (Task Oriented
Assessment of Clinical Skills) in IMM and FCPS-II Clinical
examinations. Inclusion of foreign examiners adds to the
credibility of its qualifications at an international level.
It is important to note that in the overall scenario of health
delivery over 85% of the total functioning and registered health
care specialists of the country have been provided by the CPSP.
To coordinate training and examination, and provide assistance
to the candidates stationed in cities other than Karachi, the
College has established 14 Regional Centers (including five
Provincial Headquarter Centers) in the country. The five
Provincial Headquarter Centers, in addition to organizing the
capacity building workshops/short courses also have facilities
of libraries, I.T, and evaluation of synopses and dissertations
along with providing guidance to the candidates in conducting
their research work.
The training towards Fellowship can be undertaken in more than
192 accredited medical institutions throughout the country
and 86 accredited institutions abroad. The total number of
trainees in these institutions is over 17860, who are completing
residency programs with around 3190 supervisors. These
continuous efforts of the College have even more importantly
developed a credible system of postgraduate medical
education for the country. The College strives to make its
courses and training programs ‘evidence’ and needs ‘based’
so as to meet international standards as well as to cater to the
specialist healthcare needs not only for this country but also for
the entire region.
Prof. Zafar Ullah Chaudhry
President
College of Physicians and Surgeons Pakistan

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GENERAL REGULATIONS
Candidate will be admitted to the examination in the name
(surname and other names) as given in the MBBS degree and
PMDC certificate. CPSP will not entertain any application for
change of name on the basis of marriage / divorce /deed.
REGISTRATION AND SUPERVISION
All training must be supervised, and trainees are required to
register with the Registration and Research Cell (R&RC) within
30 days of starting their training for the Intermediate Module.
In case of delay in registration, the start of training will be
considered from the date of receipt of application by the R&RC.
Registration forms are available in R&RC and in the Regional
Centers. They can also be downloaded from the CPSP Website.
Training is compulsorily monitored by an approved supervisor
who is a CPSP fellow or a specialist with relevant postgraduate
qualifications registered at the R&RC. The trainees are not
allowed to work simultaneously in any other department/
institutions for financial benefit and/or for other academic
qualifications
APPROVED TRAINING CENTRES
Training must be undertaken in units, departments and
institutions approved by the College. A current list of approved
institutions is available from the College and its Regional
Centres as well as on the College website: www.cpsp.edu.pk
INDUCTION
As per, CPSP Notification No. CPSP/Secy/2013{20-A) dated
September 24, 2013:
Candidates are required to specify at the time of registration,
whether they will pursue straight fellowship in General
Medicine or would like to join group A or B in Intermediate
Module (IMM),which comprise of:
REGULATIONS
TRAINING AND
EXAMINATION
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GROUP A
GROUP B
• Cardiology
• Cardiology
• Pulmonology
• Dermatology
• Nephrology
• Gastroenterology
• Neurology
• Medical Oncology
• Clinical Heamatology • Clinical Heamatology
Candidates will be eligible to pursue Post-IMM(FCPS II) training
in any of the specialty of the opted group(A/B), subject to
availability of residency slot in an accredited institution.
No change of group is allowed after induction.
DURATION
The duration of training for the Intermediate Module (IMM)
is two (2) years; and residents become eligible to appear in
Intermediate Module examination upon completion of IMM
training.
ROTATIONS
• The trainees in straight fellowship in General Medicine
shall do rotations of 02 months each in four of the
following specialties: Cardiology, (mandatory)
Dermatology, Gastroenterology, Medical Oncology,
Nephrology, Neurology and Pulmonology.
• The trainees in groups A and B will complete rotations
of 02 months in cardiology & any other three specialties
included in the opted group.
COMPONENTS OF TRAINING
Mandatory Workshops
It is mandatory for all trainees to attend the following CPSP
certified workshops/course in the first year of training:
1. Introduction to Computer and Internet
2. Research Methodology and Dissertation Writing
3. Communication Skills
4. Basic Life Support (BLS) Course
Any other workshop/s as may be introduced by the CPSP.

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NOTE: 1) The workshops are conducted by the Department
of Medical Education and the candidates are advised to get
registered online. The BLS course is conducted by the Advanced
Skills Department (ASD) and the registration form is to be
submitted with the ASD separately.
2) No candidate will be allowed to appear in IMM examination
without attending the abovementioned workshops and BLS
course.
E-logbook
The CPSP council has made e-logbook system mandatory
for trainees of all residency programs inducted from July
2011. Upon registration with RTMC each trainee is allotted a
registration number and a password to log on to the e-logbook
on the CPSP website. The trainee is required to enter all work
performed and the academic activities undertaken in the
logbook on daily basis. The concerned supervisor is required
to verify the entries made by the trainee. This system ensures
timely entries by the trainee and prompt verification by the
supervisor. It also helps in monitoring the progress of trainees
and vigilance of supervisors.
Work place based assessment tools like Mini CEX and DOPS are
being developed. Once they are developed, the trainees will
be required to undergo these formative assessment tools and
make their entries in the e-logbook to document attainment of
of competence.
Research (Dissertation / Two Papers)
One of the training requirements for fellowship trainee is a
dissertation or two research papers on a topic related to the
field of specialization. For trainees of straight fellowship
program in General Medicine the synopsis of dissertation or
research papers must be submitted to the Registration and
Research Cell (R&RC) in the first year of the Intermediate
Module. Trainees going to subspecialty (Group A&B) must
submit the synopsis in first year of training of the subspecialty
(i.e. 3rd year of FCPS training).
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Training Progression
Training should incorporate the principle of gradually
increasing responsibility, and provide each trainee with a
sufficient scope, volume and variety of experience in a range
of settings that include inpatients, outpatients, emergency and
intensive care.
Instructional Methodology
Teaching occurs using several methods that range from formal
lectures to planned clinical experiences. The learning domains
include knowledge, skills, attitudes and practices relevant to
the discipline. College of Physicians and Surgeons Pakistan has
developed its own competency model as under:
In order to achieve the competencies of CPSP model, all
curriculum components including instructional methods should
be appropriately aligned to competency network.
The theoretical part of the curriculum presents the current body
of knowledge necessary for practice. This can be imparted using
lectures, grand teaching rounds, clinico-pathological meetings,
morbidity/mortality review meetings, literature reviews and
presentations, journal clubs, self directed learning, conferences
and seminars.
Clinical learning is organized to provide appropriate expertise
and competence necessary to evaluate and manage common
clinical problems. Demonstration in outpatient clinics and
wards and procedural skill training on simulators, manikins and
patients are all practical training modalities.

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ASSESSMENT
ELIGIBILITY REQUIREMENTS
For appearing in Intermediate Module examination a candidate
should have:
• Passed FCPS I in Medicine and Allied or granted exemption.
• Registered with the Registration &Research Cell (R&RC).
Completed two years of training under an approved
supervisor in an institution recognized by CPSP. A
certificate of completion of training must be submitted.
• Completed entries in e-logbook along with validation by
the supervisor.
• Submitted certificates of attendance of mandatory
workshops.
• Should have submitted synopsis of dissertation or research
articles.
EXAMINATION SCHEDULE
• The Intermediate Module theory examination will be held
twice a year.
• English shall be the medium of all examinations for theory
and TOACS.
• Theory examinations are held in various cities of the
country usually at Abbottabad, Bahawalpur, Faisalabad,
Hyderabad, Islamabad, Karachi, Nawabshah, Larkana,
Lahore, Multan, Peshawar and Quetta centres. The College
shall decide where to hold TOACS examinations depending
on the number of candidates in a city and shall inform the
candidates accordingly.
• The College will notify of any change in the centres, the
dates and format of the examination.
• A competent authority appointed by the College has the
power to debar any candidate from any examination if it is
satisfied that the candidate has indulged in unfair
practices in College examination, misconduct or because
of any other disciplinary reason.

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EXAMINATION FEES
• Fee deposited for a particular examination shall not be
carried over to the next examination in case of withdrawal,
absence or exclusion.
• Applications along with the prescribed examination fee
and required documents must be submitted by the last
date notified for this purpose before each examination.
• The details of examination fee and fee for change of
centre, subject, etc shall be notified before each
examination.
REFUND OF FEES
If after submitting an application for examination, a candidate
decides not to appear, a written request for a refund must be
submitted before the last date for withdrawal with the receipt
of applications. In such cases a refund is admissible to the
extent of 75% of fees only. No request for refund will be accepted
after the closing date for receipt of applications for refund.
If an application is rejected by the CPSP, 75% of the
examination fee will be refunded, the remaining 25% being
retained as a processing charge. No refund will be made for fees
paid for any other reason, e.g. late fee, change of centre/subject
fee, etc.
FORMAT OF EXAMINATION
Intermediate Module examination consists of the following two
components:
Theory Examination:
Theory examination consists of:
Paper I: 100 Single Best Answer type of MCQs
Paper II : 160 Single Best Answer type of MCQs, out of which
the candidate has to attempt 100 MCQs. The details of which
are given below:
• Paper I will be common for all trainees and shall cover
the course content comprising Principles and Practice of
Medicine.
• Paper II shall consist of two sections.

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9
Section A will be mandatory for all trainees and will
consist of 40 MCQs of General Medicine and Cardiology.
Section B will have 120 MCQs, in six blocks with 20
MCQs in each block. Candidates will be required to
attempt any three blocks of their choice (60 MCQs).
Clinical Examination
To test basic clinical skills, the clinical examination consists of:
TOACS (Task Oriented Assessment of Clinical Skills)
TOACS
TOACS will comprise of 12 to 20 stations with a minimum
duration of 6 minutes and change over time of one minute for
the candidate to move from one station to the other.
TOACS shall be same for all trainees and shall be based on core
competencies covering basic clinical and procedural skills,life
supporting skills and communication skills. It will also include
one station on research synopsis and other on e-log. There
will be two types of stations: static and interactive. On
static stations the candidate will be presented with patient data,
a clinical problem or a research study and will be asked to give
written responses about the questions asked. At the interactive
stations the candidate will have to demonstrate a competency,
for example, taking history, performing a clinical examination,
counseling. One examiner will be present at each interactive
station and will either rate the performance of the candidate or
ask questions testing reasoning and problem solving skills.
College is encouraging to have all stations to be interactive and
expects that the static stations will soon be phased out.
Candidates have to pass the theory to be eligible to sit the
TOACS examination.

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CURRICULUM FOR BASIC MEDICAL TRAINING
GOALS
The curriculum of frst two years in medicine involves balanced
and objective integration of basic medical sciences and
essential core clinical knowledge in medicine. The trainee
should be able to diagnose and manage uncomplicated
conditions prevalent in the region and also recognize, stabilize
and refer complicated cases to appropriate place / person.
Upon completion of training in intermediate module in
Medicine and allied, a resident must acquire the basic
competencies in the principles and practice of Medicine along
with outcomes in the domains of knowledge, skills and attitude
in order to:
• Provide appropriate and cost-effective care to patients at
all levels.
• Promote health and prevent disease in patients, families
and communities.
• Practice continuing professional development.
For this purpose the trainee must acquire:
• Knowledge and expertise in clinical and procedural
management of relevant diseases.
• Basics skills.
• Effective clinical judgment and decision making in dealing
with health problems using evidence based medicine.
The coverage that each area receives is not indicative of
the relative importance placed on that area in the training
program or in the examination. These are guidelines and not
comprehensive definitive lists. Only minimum levels of
expected competence have been identified but sufficient scope,
volume and variety of experience are desirable.

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EXIT OUTCOMES
By the end of second year of training in Medicine the trainee
should be able to:
a) Assess symptoms and signs
b) Formulate a differential diagnosis
c) Select appropriate investigations and accurately interpret
d) Communicate the diagnosis and prognosis
e) Institute appropriate treatment of the following clinical
conditions recognizing indications, contraindications and side
effects:
• Breathlessness
• Lethargy
• Weight gain/loss
• Nausea/Vomiting
• Pressure sores etc
CORE COMPETENCIES
The core competencies a trainee is expected to acquire at the
end of two years of training and before appearing in
Intermediate Module Examination are aligned to the CPSP
competency frame work mentioned earlier and include:
History Taking
• Understand the symptomatology and recognize alarm
symptoms
• Take history in problem situations as when patient’s
language is different from trainee’s language or when
confronted with confused and deaf patients.
• Formulate a differential diagnosis after analysis and
synthesis of identified problems
• Recognize psychological and social issues developing
due to disease or infirmity
• Show empathy with the patient
Physical Examination
• Take permission to examine and explain the procedure
• Elicit signs and use instruments with maximum care
• Comprehend the ethics of privacy and confidentiality and
apply it for individual cases
• Recognize the role of and seek help of attendants/relatives
where required

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Medical Record Keeping
• Record accurately patient’s history, examination,
differential diagnosis, investigations and management
plan
• Fill in all the required hospital record forms accurately
• Maintain records with dates and sign each entry
• Ensure that notes are accessible to all members of the
team and patients /relatives (if required)
• Use latest technology for the benefit of patient e.g. fax,
email etc
Time Management
• Set priorities for tasks to be accomplished
• Plan line of action while keeping realistic expectations of
tasks to be completed by self and others
Decision Making
• Analyze and synthesize clinical problems
• Recognize the role of and consult other members of the
health care team
• Approach tasks with flexibility
Basic Life Support
• Examine and assess a collapsed patient
• Maintain adequate airway and perform effective
cardiopulmonary resuscitation
• Control one’s own emotions and enable others to keep
calm
Communication Skills
• Use open ended questions for gaining information
• Communicate effectively with patients taking care of their
level of understanding
• Encourage questions from the patients and their relatives
• Avoid technical terms
• Use interpreters where necessary
• Provide information to patients in simple and precise
language
• Give due respect to patients and their relatives and
share information when appropriate

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• While counseling give choices and help the patient in
decision making
• Show empathy and concern during breaking bad news
• Avoid conveying unrealistic optimism
• Discuss ethics, medical procedure & legal implications
related to organ donation with the patient and their
relatives when required
Life Long Learning
• Pursue professional development activities/ programs
• Understand the role of appraisal and of assessment
• Recognize and make full use of learning opportunities
• Make effort to learn from seniors, colleagues and others
• Demonstrate proficiency in the use of information
technology
Practice Evidence Based Medicine
• Show competence in use of all sources of information e.g.
databases as Medline, library and the internet
• Use evidence to support patient care effectively
• Critically evaluate medical evidence using principles of
EBM
Uses Clinical Audit/Guidelines for patient care
• Recognize the relevance of audit to benefit patient care
• Participate in clinical audits
• Comprehend the problems and benefits of existing
guidelines
• Use local guidelines where applied
• Take care of individual patient needs when using
guidelines
Professionalism and Ethics
• Recognize the importance of Informed consent and
practice it in a manner that the patient is able to
understand it fully
• Respect the right to confidentiality
• Maintain patient’s confidentiality
• Use and share all information with the patient and their

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relatives as and where appropriate
• Partake legal responsibilities of writing Death certificate,
mental health certificate
• Show responsibility in maintaining continuity of care
• Ensure satisfactory completion of delegated tasks by the
end of the shift/day with appropriate handover
• Display non discriminatory attitude towards all the patients
• Refrain from giving unnecessary personal comments
• Exercise care in managing inappropriate behaviour e.g.
aggression, violence, sexual harassment in patients
• Recognize own limitations and accept constructive criticism
• Act as a responsible member of health care team
Patient Education
• Educate patients about: disease, investigations, therapy,
possible alternatives /choices, rehabilitation etc.
• Counsel patients, explaining individual treatment plans
and the actions to be taken if the condition deteriorates or
improves
• Encourage patients to access further information / patient
support groups
Disease Prevention
• Identify role of environmental and lifestyle risk factors,
such as diet, exercise, social deprivation, occupation and
substance abuse in disease causation
• Comprehend the Epidemiology and screening procedures
for risk factors
• Provide support and advice on quitting the use of tobacco/
alcohol etc.
• Assess individual patient’s risk factors
• Encourage participation in appropriate disease prevention
or screening programs
Teaching and Training (Pedagogy)
• Communicate and share information with all members of
health care team
• Adopt Learner-centered approach while teaching/training
• Demonstrate willingness, enthusiasm and patience to
teach

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• Seek feedback from peers as well as from juniors
• Make best use of all teaching opportunities
• Develop effective presentation skills
• Use effectively multiple audio-visual aids for presentation
Safe Management while on Call
• Recognize medical indications for urgent investigations
and therapy
• Identify skills and competencies of other members of the
‘on- call ‘ team
• Prioritize the tasks to be carried out
• Call for help and refer the case whenever required
• Effectively interact with other health care professionals
• Keep patients and relatives informed
• Hand over all the information to the proceeding team staff
safely
Discharge Planning
• Recognize the impact of unnecessary hospitalization
• Educate the patient and relatives regarding impact of
physical problems on daily activities
• Liaise and communicate with patient, family and primary
care services
• Write reports for appropriate bodies
Resuscitation and Advanced Cardiac Life Support
• Recognize critically ill patients.
• Practice Advanced cardiac life support algorithms
• Recognize cardiac arrhythmias
• Manage patients on commonly used anti arrhythmic and
cardiac support drugs
• Perform emergency defibrillation
• Lead a cardiac arrest team
• Understand Legal and ethical considerations regarding; Do
not resuscitate orders (DNR)
• Act with empathy and sensitivity while dealing with
patients and families

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Nutrition
• Identify impact of disease on nutritional status and
malnutrition on clinical outcomes
• Assess nutritional status of patients
• Recognize cultural and religious issues
• Utilize proper routes of nutrition support
• Refer cases to nutritionist when required

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PROCEDURAL COMPETENCIES
The clinical competencies, a specialist must have, are varied
and complex. A complete list of the procedures and skills
for trainees is given below. The level of competence to be
achieved each year is specified according to the key, as follows:
1. Observer status
2. Assistant status
3. Performed under supervision
4. Performed independently

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Pleural Aspiration Peritoneal Aspiration Lumbar puncture Nasogastric Intubation Uretheral catheterization Recording and reporting ECG
Proctoscopy Endotracheal Intubation Cardio-Pulmonary Resuscitation (CPR) Insertion of CVP lines Arterial puncture Urine
Examination Liver biopsy Pleural biopsy Joint aspiration Bone marrow aspiration Renal biopsy
1,2 1,2 11,2 1,2 1 - 11,2 1 - 3 1 - - - -
222225-111-11----
3323321232-321-1-
4434431333-322111
2222251222-111111
44444413331322111
22222511222111-11
8 8 8 8 8 20 3 6 6 6 2 4 4 3 1 3 2
2222251211-111-1-
FIRST YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

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Haemodialysis Upper G.I. Endoscopy Lower G.I. Endoscopy Bronchoscopy Abdominal Ultrasound Exercise Tolerence Test
Echocardiography CT Scan Head,Chest,Abdomen EEG EMG/NCS Chest Intubation Pericardiocentesis MRI Brain
-------------
-------------
1------1-----
11-11-11----1
11-11-11----1
21111-11----1
11111-11----1
32122-23----2
1------1-----
FIRST YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

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Pleural Aspiration Peritoneal Aspiration Lumbar puncture Nasogastric Intubation Uretheral catheterization Recording and reporting ECG
Proctoscopy Endotracheal Intubation (Cardio-Pulmonary Resuscitation (CPR Insertion of CVP lines Arterial puncture Urine
Examination Liver biopsy Pleural biopsy Joint aspiration Bone marrow aspiration Renal biopsy
44444413332422111
11111111111111-1-
44444413332422111
11111111111111111
22222222222222121
SECOND YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

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Haemodialysis Upper G.I. Endoscopy Lower G.I. Endoscopy Bronchoscopy Abdominal Ultrasound Exercise Tolerence Test
Echocardiography CT Scan Head EEG EMG/NCS Chest Intubation Pericardiocentesis MRI Brain and Spine CT Scan
Head,Chest,Abdomen Depression and anxiety
211111111111111
111111111111111
211111111111111
1-1-11111111111
212122222222222
SECOND YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

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Thromvolysis in acute MI Management of Arrythmias - Drug / Defibrillation ECG recordings and reporting ETT ECHO CPR
Pleural Aspiration Pleural Biopsy Chest intubation Broncoscopy Pulmonary function test Blood gases interpertation
CT Scan interpretation MRI interpretation EEG interpretation EMG interpretation
1,2,3 1,2,3 1,2,3
1,2 11,2
1,2,3
1 1 1 11,2
1,2,3 1,2,3
11
646242
311222
4211
CARDIOLOGY (two month rotation)
PULMONOLGY (two month rotation)
NEUROLOGY (two month rotation)

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Peritonial Aspiration Liver Biopsy Upper GI Endoscopy Colonoscopy / sigmoidoscopy V
ariceal banding / Sclerothrepy
Chemeotherapy Radiotherapy
Haemodialysis Renal Biopsy Insertion of double lumen catheter
1,2,3
1111
1,2 1
1,2,3
1,2 1,2
32222
42
422
GASTROENTEROLOGY (two month rotation)
MEDICAL ONCOLOGY (two month rotation)
NEPHROLOGY (two month rotation)
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211121
1,2 1,2 1 11,2 1,2
20 10 10 1 510
Routine Haematology Haemoglobinopathies Coagulation disorders Stem cell transplantation Malignant hematology Blood transfusion
CLINICAL HEMA
TOLOGY (two month rotation
)

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Psoriasis Scabies HS Purpura Erythema Nodosum Fixed Drug Eruption
DERMA
TOLOGY

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SYLLABUS
Cardiology
• Preventive Cardiology
• Coronary Heart Disease
• Acute Rheumatic Fever
• Rheumatic Heart Disease
• Valvular Heart disease
• Infective Endocarditis
• Dizziness/ Syncope and Palpitation
• Arrythmias
• Haemodynamic disturbances
• Hypotension and shock
• CPR, Basic Life Support,
• Advanced Cardiac Life Support
• Heart Failure
• Myocardiditis Cardiomyopathies
• Pericarditis
• Hypertension
Pulmonology
• Prevention of Respiratory diseases
• Cough, Haemoptysis, Dyspnoea
• Pneumonias, Lung abscess
• Bronchiectasis
• Bronchial Asthma
• COPD
• Pulmonary Tuberculosis
• Pleural Effusion
• Pneumothorax
• Lung Cancer
• Interstitial Lung disease and fibrosis
• DVT/ Pulmonary embolism
• Oxygen therapy
• Assisted ventilation
Medical Oncology Including Hematology
• Anemias
• Haemoglobinopathies
• Neutropenia, Neutropenic sepsis

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• Bone Marrow failure
• Transfusion of blood products
• Leukemia
• Lymphomas other myeloproliferative disorders
• Multiple myeloma
• Disorders of Hemostasis
• Platelet disorders, DIC
• Bleeding disorders
• Hypercoagilable state
• Anticoagulation
• Prevention of cancer, staging of cancer
• Oncological emergencies
• Hypercalcemia
• Malignant effusions
GI Tract and Liver
• Nausea, vomiting
• Hiccup, Dyspepsia
• GERD, Dysphagia
• Upper GI bleed
• Oesophageal varices
• Gastritis, NSAID Gastritis
• Peptic ulcer disease
• Diarrhea, Malabsorption syndrome
• Coelic disease
• Irritable bowel disease
• Inflammatory bowel disease
• Constipation
• Antibiotic associated colitis
• Lower GI and rectal bleed
• Abdominal distension
• Jaundice, Acute Hepatitis
• Chronic Hepatitis, Chronic liver disease
• Portal Hypertension
• Decompensated Cirrhosis
• Encephlopathy
• Fulminant liver failure
Neurology
• Headache, Facial pain
• Meningitis, Encephalitis
• Brain abscess, Epilepsy
• Intracranial space occupying lesions
• Benign intracranial hypertension
• Raised intracranial pressure
• TIAs, Stroke, weakness and paralysis
• Sub-arachnoid hemorrhage
• Coma
• Parkinsonism, other movement disorders
• Spasticity
• Dementia, Multiple sclerosis
• Polyneuropathy
• Motor neuron diseases
• Subacute combined degeneration of spinal cord
• Disorders of neuromuscular transmission
• Myopathies, Periodic paralysis
Nephrology
• Acute Renal Failure
• Chronic Renal Failure
• Glomerulopathies
• Nephrotic Syndrome, Proteinuria
• Haematuria
• Urinary infections
• Cystic diseases of kidney
• Tubulointerstitial diseases
• Multisystem diseases with kidney involvement
• Renal replacement therapy
• Hypertension and kidney
Endocrinology, Diabetes Mellitus, Lipid Disorders
• Diabetes Mellitus
• Diabetic Coma
• The hypoglycemic state
• Diseases of Hypothalmus, Pituitary gland
• Disorders of thyroid and parathyroid glands
• Adrenocortical deficiency
• Cushing Syndrome
• Clinical uses of corticosteroids
• Dyslipidemias
• Metabolic bone disease
Fluid, Electrolytes, Acid Base Disorders and Poisoning
• Hypo and hyper natremia
• Hypo and hyper kalemia
• Hypo and hyper calcemia
• Acid Base Disorders
• Hyperosmolar Disorders
• Anion gap
• Fluid management
• Poisoning: Salicylates, Tricyclics
• Benzodiazepam, Narcotics
• Paracetamol
• Organophosphorous compounds
Infections, Disorders due to Physical agents and Environment
• Fever of unknown origin
• Sepsis syndrome
• Infections in immune compromised host
• Nosocomial infections
• Infections due to resistant organisms, MRSA, Mycobacterium
• Emerging Infections
o Ebola Virus
o SARS
o MERS
o Congo Crimean Hemorrhagic Fever
o Dengue Fever
o Nigleria Fowleri
• HIV, AIDS
• Sexually transmitted diseases
• Infections in drug users
• Food poisoning
• Acute Infectious diarrhea
• Bacillary dysentery
• Typhoid and Paratyphoid fevers
• Malaria
• Giardiasis
• Amoebiasis
• Leishmaniasis
Page 1

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INTERMEDIATE MODULE
IN
MEDICINE & ALLIED
REQUIREMENTS FOR TRAINING & EXAMINATION

Page 5
THIS IS AN EVOLVING DOCUMENT
The College of Physicians and Surgeons Pakistan
would appreciate any criticism, suggestions, advice from the
readers and users of this document. Comments may be sent in
writing or by e-mail to the CPSP at:
DIRECTORATE OF NATIONAL RESIDENCY PROGRAM (DNRP)
College of Physicians and Surgeons Pakistan (CPSP)
7th Central Street, Defence Housing Authority, Karachi-75500.
[email protected]

Page 6
MEDICINE & ALLIED
01 Introduction
03 Training and Examination
07 Assessment
25 Syllabus
CONTENTS
Page 7
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1
The College was established in 1962 through an ordinance of
the Federal Government. The objectives and functions of the
College include: promotion of specialist practice by securing
improvement of teaching and training; arranging postgraduate
medical, surgical and other specialist training; holding and
conducting examinations for awarding College diplomas and
admission to the Fellowships of the College.
Since its inception, the College has taken great strides in
improving postgraduate medical and dental education in
Pakistan. Competency-based structured Residency Programs
have now been developed, along with criteria for accreditation
of training institutions, and for the appointment of supervisors
and examiners. The format of examinations has evolved over
the years to achieve greater objectivity and reliability in
methods of assessment. The recognition of the standards of
College qualifications nationally and internationally,
particularly of its Fellowship, has enormously increased the
number of trainees, and consequently the number of training
institutions and the supervisors. The rapid increase in
knowledge base of medical sciences and consequent
emergence of new subspecialties have gradually increased the
number of CPSP fellowship disciplines to seventy three.
After completing two years of core training during IMM, the
trainees are allowed to proceed to the advance phase of
FCPS training in the specific specialty of choice for 2-3 years.
However, it is mandatory to qualify IMM examination before
taking the FCPS-II exit examination. The work performed by the
trainee is to be recorded in the e-Iog book on daily basis. The
purpose of the e-Iog is to ensure that the entries are made on a
regular basis and to avoid belated and fabricated entries. It will
hence promote accuracy, authenticity and vigilance on the part
of trainees and the supervisors.
INTRODUCTION
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2
The average number of candidates taking CPSP examinations
each year around 23,000. The College conducts examinations
for FCPS I (11 groups of disciplines), IMM, FCPS II (73
disciplines), MCPS (22 disciplines), including MCPS in HPE and
MCPS in HCSM. A large number of Fellows and senior medical
teachers from within the country and overseas are involved
at various levels of examinations of the College. The College,
in its endeavor to decrease inter-rater variability and increase
fairness and transparency, is using TOACS (Task Oriented
Assessment of Clinical Skills) in IMM and FCPS-II Clinical
examinations. Inclusion of foreign examiners adds to the
credibility of its qualifications at an international level.
It is important to note that in the overall scenario of health
delivery over 85% of the total functioning and registered health
care specialists of the country have been provided by the CPSP.
To coordinate training and examination, and provide assistance
to the candidates stationed in cities other than Karachi, the
College has established 14 Regional Centers (including five
Provincial Headquarter Centers) in the country. The five
Provincial Headquarter Centers, in addition to organizing the
capacity building workshops/short courses also have facilities
of libraries, I.T, and evaluation of synopses and dissertations
along with providing guidance to the candidates in conducting
their research work.
The training towards Fellowship can be undertaken in more than
192 accredited medical institutions throughout the country
and 86 accredited institutions abroad. The total number of
trainees in these institutions is over 17860, who are completing
residency programs with around 3190 supervisors. These
continuous efforts of the College have even more importantly
developed a credible system of postgraduate medical
education for the country. The College strives to make its
courses and training programs ‘evidence’ and needs ‘based’
so as to meet international standards as well as to cater to the
specialist healthcare needs not only for this country but also for
the entire region.
Prof. Zafar Ullah Chaudhry
President
College of Physicians and Surgeons Pakistan

Page 9
MEDICINE & ALLIED
3
GENERAL REGULATIONS
Candidate will be admitted to the examination in the name
(surname and other names) as given in the MBBS degree and
PMDC certificate. CPSP will not entertain any application for
change of name on the basis of marriage / divorce /deed.
REGISTRATION AND SUPERVISION
All training must be supervised, and trainees are required to
register with the Registration and Research Cell (R&RC) within
30 days of starting their training for the Intermediate Module.
In case of delay in registration, the start of training will be
considered from the date of receipt of application by the R&RC.
Registration forms are available in R&RC and in the Regional
Centers. They can also be downloaded from the CPSP Website.
Training is compulsorily monitored by an approved supervisor
who is a CPSP fellow or a specialist with relevant postgraduate
qualifications registered at the R&RC. The trainees are not
allowed to work simultaneously in any other department/
institutions for financial benefit and/or for other academic
qualifications
APPROVED TRAINING CENTRES
Training must be undertaken in units, departments and
institutions approved by the College. A current list of approved
institutions is available from the College and its Regional
Centres as well as on the College website: www.cpsp.edu.pk
INDUCTION
As per, CPSP Notification No. CPSP/Secy/2013{20-A) dated
September 24, 2013:
Candidates are required to specify at the time of registration,
whether they will pursue straight fellowship in General
Medicine or would like to join group A or B in Intermediate
Module (IMM),which comprise of:
REGULATIONS
TRAINING AND
EXAMINATION
 Page 10
MEDICINE & ALLIED
4
GROUP A
GROUP B
• Cardiology
• Cardiology
• Pulmonology
• Dermatology
• Nephrology
• Gastroenterology
• Neurology
• Medical Oncology
• Clinical Heamatology • Clinical Heamatology
Candidates will be eligible to pursue Post-IMM(FCPS II) training
in any of the specialty of the opted group(A/B), subject to
availability of residency slot in an accredited institution.
No change of group is allowed after induction.
DURATION
The duration of training for the Intermediate Module (IMM)
is two (2) years; and residents become eligible to appear in
Intermediate Module examination upon completion of IMM
training.
ROTATIONS
• The trainees in straight fellowship in General Medicine
shall do rotations of 02 months each in four of the
following specialties: Cardiology, (mandatory)
Dermatology, Gastroenterology, Medical Oncology,
Nephrology, Neurology and Pulmonology.
• The trainees in groups A and B will complete rotations
of 02 months in cardiology & any other three specialties
included in the opted group.
COMPONENTS OF TRAINING
Mandatory Workshops
It is mandatory for all trainees to attend the following CPSP
certified workshops/course in the first year of training:
1. Introduction to Computer and Internet
2. Research Methodology and Dissertation Writing
3. Communication Skills
4. Basic Life Support (BLS) Course
Any other workshop/s as may be introduced by the CPSP.

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MEDICINE & ALLIED
5
NOTE: 1) The workshops are conducted by the Department
of Medical Education and the candidates are advised to get
registered online. The BLS course is conducted by the Advanced
Skills Department (ASD) and the registration form is to be
submitted with the ASD separately.
2) No candidate will be allowed to appear in IMM examination
without attending the abovementioned workshops and BLS
course.
E-logbook
The CPSP council has made e-logbook system mandatory
for trainees of all residency programs inducted from July
2011. Upon registration with RTMC each trainee is allotted a
registration number and a password to log on to the e-logbook
on the CPSP website. The trainee is required to enter all work
performed and the academic activities undertaken in the
logbook on daily basis. The concerned supervisor is required
to verify the entries made by the trainee. This system ensures
timely entries by the trainee and prompt verification by the
supervisor. It also helps in monitoring the progress of trainees
and vigilance of supervisors.
Work place based assessment tools like Mini CEX and DOPS are
being developed. Once they are developed, the trainees will
be required to undergo these formative assessment tools and
make their entries in the e-logbook to document attainment of
of competence.
Research (Dissertation / Two Papers)
One of the training requirements for fellowship trainee is a
dissertation or two research papers on a topic related to the
field of specialization. For trainees of straight fellowship
program in General Medicine the synopsis of dissertation or
research papers must be submitted to the Registration and
Research Cell (R&RC) in the first year of the Intermediate
Module. Trainees going to subspecialty (Group A&B) must
submit the synopsis in first year of training of the subspecialty
(i.e. 3rd year of FCPS training).

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MEDICINE & ALLIED
6
Training Progression
Training should incorporate the principle of gradually
increasing responsibility, and provide each trainee with a
sufficient scope, volume and variety of experience in a range
of settings that include inpatients, outpatients, emergency and
intensive care.
Instructional Methodology
Teaching occurs using several methods that range from formal
lectures to planned clinical experiences. The learning domains
include knowledge, skills, attitudes and practices relevant to
the discipline. College of Physicians and Surgeons Pakistan has
developed its own competency model as under:
In order to achieve the competencies of CPSP model, all
curriculum components including instructional methods should
be appropriately aligned to competency network.
The theoretical part of the curriculum presents the current body
of knowledge necessary for practice. This can be imparted using
lectures, grand teaching rounds, clinico-pathological meetings,
morbidity/mortality review meetings, literature reviews and
presentations, journal clubs, self directed learning, conferences
and seminars.
Clinical learning is organized to provide appropriate expertise
and competence necessary to evaluate and manage common
clinical problems. Demonstration in outpatient clinics and
wards and procedural skill training on simulators, manikins and
patients are all practical training modalities.
 Page 13
MEDICINE & ALLIED
7
ASSESSMENT
ELIGIBILITY REQUIREMENTS
For appearing in Intermediate Module examination a candidate
should have:
• Passed FCPS I in Medicine and Allied or granted exemption.
• Registered with the Registration &Research Cell (R&RC).
Completed two years of training under an approved
supervisor in an institution recognized by CPSP. A
certificate of completion of training must be submitted.
• Completed entries in e-logbook along with validation by
the supervisor.
• Submitted certificates of attendance of mandatory
workshops.
• Should have submitted synopsis of dissertation or research
articles.
EXAMINATION SCHEDULE
• The Intermediate Module theory examination will be held
twice a year.
• English shall be the medium of all examinations for theory
and TOACS.
• Theory examinations are held in various cities of the
country usually at Abbottabad, Bahawalpur, Faisalabad,
Hyderabad, Islamabad, Karachi, Nawabshah, Larkana,
Lahore, Multan, Peshawar and Quetta centres. The College
shall decide where to hold TOACS examinations depending
on the number of candidates in a city and shall inform the
candidates accordingly.
• The College will notify of any change in the centres, the
dates and format of the examination.
• A competent authority appointed by the College has the
power to debar any candidate from any examination if it is
satisfied that the candidate has indulged in unfair
practices in College examination, misconduct or because
of any other disciplinary reason.

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MEDICINE & ALLIED
8
EXAMINATION FEES
• Fee deposited for a particular examination shall not be
carried over to the next examination in case of withdrawal,
absence or exclusion.
• Applications along with the prescribed examination fee
and required documents must be submitted by the last
date notified for this purpose before each examination.
• The details of examination fee and fee for change of
centre, subject, etc shall be notified before each
examination.
REFUND OF FEES
If after submitting an application for examination, a candidate
decides not to appear, a written request for a refund must be
submitted before the last date for withdrawal with the receipt
of applications. In such cases a refund is admissible to the
extent of 75% of fees only. No request for refund will be accepted
after the closing date for receipt of applications for refund.
If an application is rejected by the CPSP, 75% of the
examination fee will be refunded, the remaining 25% being
retained as a processing charge. No refund will be made for fees
paid for any other reason, e.g. late fee, change of centre/subject
fee, etc.
FORMAT OF EXAMINATION
Intermediate Module examination consists of the following two
components:
Theory Examination:
Theory examination consists of:
Paper I: 100 Single Best Answer type of MCQs
Paper II : 160 Single Best Answer type of MCQs, out of which
the candidate has to attempt 100 MCQs. The details of which
are given below:
• Paper I will be common for all trainees and shall cover
the course content comprising Principles and Practice of
Medicine.
• Paper II shall consist of two sections.

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MEDICINE & ALLIED
9
Section A will be mandatory for all trainees and will
consist of 40 MCQs of General Medicine and Cardiology.
Section B will have 120 MCQs, in six blocks with 20
MCQs in each block. Candidates will be required to
attempt any three blocks of their choice (60 MCQs).
Clinical Examination
To test basic clinical skills, the clinical examination consists of:
TOACS (Task Oriented Assessment of Clinical Skills)
TOACS
TOACS will comprise of 12 to 20 stations with a minimum
duration of 6 minutes and change over time of one minute for
the candidate to move from one station to the other.
TOACS shall be same for all trainees and shall be based on core
competencies covering basic clinical and procedural skills,life
supporting skills and communication skills. It will also include
one station on research synopsis and other on e-log. There
will be two types of stations: static and interactive. On
static stations the candidate will be presented with patient data,
a clinical problem or a research study and will be asked to give
written responses about the questions asked. At the interactive
stations the candidate will have to demonstrate a competency,
for example, taking history, performing a clinical examination,
counseling. One examiner will be present at each interactive
station and will either rate the performance of the candidate or
ask questions testing reasoning and problem solving skills.
College is encouraging to have all stations to be interactive and
expects that the static stations will soon be phased out.
Candidates have to pass the theory to be eligible to sit the
TOACS examination.
 Page 16
MEDICINE & ALLIED
10
CURRICULUM FOR BASIC MEDICAL TRAINING
GOALS
The curriculum of frst two years in medicine involves balanced
and objective integration of basic medical sciences and
essential core clinical knowledge in medicine. The trainee
should be able to diagnose and manage uncomplicated
conditions prevalent in the region and also recognize, stabilize
and refer complicated cases to appropriate place / person.
Upon completion of training in intermediate module in
Medicine and allied, a resident must acquire the basic
competencies in the principles and practice of Medicine along
with outcomes in the domains of knowledge, skills and attitude
in order to:
• Provide appropriate and cost-effective care to patients at
all levels.
• Promote health and prevent disease in patients, families
and communities.
• Practice continuing professional development.
For this purpose the trainee must acquire:
• Knowledge and expertise in clinical and procedural
management of relevant diseases.
• Basics skills.
• Effective clinical judgment and decision making in dealing
with health problems using evidence based medicine.
The coverage that each area receives is not indicative of
the relative importance placed on that area in the training
program or in the examination. These are guidelines and not
comprehensive definitive lists. Only minimum levels of
expected competence have been identified but sufficient scope,
volume and variety of experience are desirable.

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MEDICINE & ALLIED
11
EXIT OUTCOMES
By the end of second year of training in Medicine the trainee
should be able to:
a) Assess symptoms and signs
b) Formulate a differential diagnosis
c) Select appropriate investigations and accurately interpret
d) Communicate the diagnosis and prognosis
e) Institute appropriate treatment of the following clinical
conditions recognizing indications, contraindications and side
effects:
• Breathlessness
• Lethargy
• Weight gain/loss
• Nausea/Vomiting
• Pressure sores etc
CORE COMPETENCIES
The core competencies a trainee is expected to acquire at the
end of two years of training and before appearing in
Intermediate Module Examination are aligned to the CPSP
competency frame work mentioned earlier and include:
History Taking
• Understand the symptomatology and recognize alarm
symptoms
• Take history in problem situations as when patient’s
language is different from trainee’s language or when
confronted with confused and deaf patients.
• Formulate a differential diagnosis after analysis and
synthesis of identified problems
• Recognize psychological and social issues developing
due to disease or infirmity
• Show empathy with the patient
Physical Examination
• Take permission to examine and explain the procedure
• Elicit signs and use instruments with maximum care
• Comprehend the ethics of privacy and confidentiality and
apply it for individual cases
• Recognize the role of and seek help of attendants/relatives
where required

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MEDICINE & ALLIED
12
Medical Record Keeping
• Record accurately patient’s history, examination,
differential diagnosis, investigations and management
plan
• Fill in all the required hospital record forms accurately
• Maintain records with dates and sign each entry
• Ensure that notes are accessible to all members of the
team and patients /relatives (if required)
• Use latest technology for the benefit of patient e.g. fax,
email etc
Time Management
• Set priorities for tasks to be accomplished
• Plan line of action while keeping realistic expectations of
tasks to be completed by self and others
Decision Making
• Analyze and synthesize clinical problems
• Recognize the role of and consult other members of the
health care team
• Approach tasks with flexibility
Basic Life Support
• Examine and assess a collapsed patient
• Maintain adequate airway and perform effective
cardiopulmonary resuscitation
• Control one’s own emotions and enable others to keep
calm
Communication Skills
• Use open ended questions for gaining information
• Communicate effectively with patients taking care of their
level of understanding
• Encourage questions from the patients and their relatives
• Avoid technical terms
• Use interpreters where necessary
• Provide information to patients in simple and precise
language
• Give due respect to patients and their relatives and
share information when appropriate

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MEDICINE & ALLIED
13
• While counseling give choices and help the patient in
decision making
• Show empathy and concern during breaking bad news
• Avoid conveying unrealistic optimism
• Discuss ethics, medical procedure & legal implications
related to organ donation with the patient and their
relatives when required
Life Long Learning
• Pursue professional development activities/ programs
• Understand the role of appraisal and of assessment
• Recognize and make full use of learning opportunities
• Make effort to learn from seniors, colleagues and others
• Demonstrate proficiency in the use of information
technology
Practice Evidence Based Medicine
• Show competence in use of all sources of information e.g.
databases as Medline, library and the internet
• Use evidence to support patient care effectively
• Critically evaluate medical evidence using principles of
EBM
Uses Clinical Audit/Guidelines for patient care
• Recognize the relevance of audit to benefit patient care
• Participate in clinical audits
• Comprehend the problems and benefits of existing
guidelines
• Use local guidelines where applied
• Take care of individual patient needs when using
guidelines
Professionalism and Ethics
• Recognize the importance of Informed consent and
practice it in a manner that the patient is able to
understand it fully
• Respect the right to confidentiality
• Maintain patient’s confidentiality
• Use and share all information with the patient and their

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MEDICINE & ALLIED
14
relatives as and where appropriate
• Partake legal responsibilities of writing Death certificate,
mental health certificate
• Show responsibility in maintaining continuity of care
• Ensure satisfactory completion of delegated tasks by the
end of the shift/day with appropriate handover
• Display non discriminatory attitude towards all the patients
• Refrain from giving unnecessary personal comments
• Exercise care in managing inappropriate behaviour e.g.
aggression, violence, sexual harassment in patients
• Recognize own limitations and accept constructive criticism
• Act as a responsible member of health care team
Patient Education
• Educate patients about: disease, investigations, therapy,
possible alternatives /choices, rehabilitation etc.
• Counsel patients, explaining individual treatment plans
and the actions to be taken if the condition deteriorates or
improves
• Encourage patients to access further information / patient
support groups
Disease Prevention
• Identify role of environmental and lifestyle risk factors,
such as diet, exercise, social deprivation, occupation and
substance abuse in disease causation
• Comprehend the Epidemiology and screening procedures
for risk factors
• Provide support and advice on quitting the use of tobacco/
alcohol etc.
• Assess individual patient’s risk factors
• Encourage participation in appropriate disease prevention
or screening programs
Teaching and Training (Pedagogy)
• Communicate and share information with all members of
health care team
• Adopt Learner-centered approach while teaching/training
• Demonstrate willingness, enthusiasm and patience to
teach

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MEDICINE & ALLIED
15
• Seek feedback from peers as well as from juniors
• Make best use of all teaching opportunities
• Develop effective presentation skills
• Use effectively multiple audio-visual aids for presentation
Safe Management while on Call
• Recognize medical indications for urgent investigations
and therapy
• Identify skills and competencies of other members of the
‘on- call ‘ team
• Prioritize the tasks to be carried out
• Call for help and refer the case whenever required
• Effectively interact with other health care professionals
• Keep patients and relatives informed
• Hand over all the information to the proceeding team staff
safely
Discharge Planning
• Recognize the impact of unnecessary hospitalization
• Educate the patient and relatives regarding impact of
physical problems on daily activities
• Liaise and communicate with patient, family and primary
care services
• Write reports for appropriate bodies
Resuscitation and Advanced Cardiac Life Support
• Recognize critically ill patients.
• Practice Advanced cardiac life support algorithms
• Recognize cardiac arrhythmias
• Manage patients on commonly used anti arrhythmic and
cardiac support drugs
• Perform emergency defibrillation
• Lead a cardiac arrest team
• Understand Legal and ethical considerations regarding; Do
not resuscitate orders (DNR)
• Act with empathy and sensitivity while dealing with
patients and families

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16
Nutrition
• Identify impact of disease on nutritional status and
malnutrition on clinical outcomes
• Assess nutritional status of patients
• Recognize cultural and religious issues
• Utilize proper routes of nutrition support
• Refer cases to nutritionist when required

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17
PROCEDURAL COMPETENCIES
The clinical competencies, a specialist must have, are varied
and complex. A complete list of the procedures and skills
for trainees is given below. The level of competence to be
achieved each year is specified according to the key, as follows:
1. Observer status
2. Assistant status
3. Performed under supervision
4. Performed independently

Page 24
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18
Pleural Aspiration Peritoneal Aspiration Lumbar puncture Nasogastric Intubation Uretheral catheterization Recording and reporting ECG
Proctoscopy Endotracheal Intubation Cardio-Pulmonary Resuscitation (CPR) Insertion of CVP lines Arterial puncture Urine
Examination Liver biopsy Pleural biopsy Joint aspiration Bone marrow aspiration Renal biopsy
1,2 1,2 11,2 1,2 1 - 11,2 1 - 3 1 - - - -
222225-111-11----
3323321232-321-1-
4434431333-322111
2222251222-111111
44444413331322111
22222511222111-11
8 8 8 8 8 20 3 6 6 6 2 4 4 3 1 3 2
2222251211-111-1-
FIRST YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor
 Page 25
MEDICINE & ALLIED
19
Haemodialysis Upper G.I. Endoscopy Lower G.I. Endoscopy Bronchoscopy Abdominal Ultrasound Exercise Tolerence Test
Echocardiography CT Scan Head,Chest,Abdomen EEG EMG/NCS Chest Intubation Pericardiocentesis MRI Brain
-------------
-------------
1------1-----
11-11-11----1
11-11-11----1
21111-11----1
11111-11----1
32122-23----2
1------1-----
FIRST YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

Page 26
MEDICINE & ALLIED
20
Pleural Aspiration Peritoneal Aspiration Lumbar puncture Nasogastric Intubation Uretheral catheterization Recording and reporting ECG
Proctoscopy Endotracheal Intubation (Cardio-Pulmonary Resuscitation (CPR Insertion of CVP lines Arterial puncture Urine
Examination Liver biopsy Pleural biopsy Joint aspiration Bone marrow aspiration Renal biopsy
44444413332422111
11111111111111-1-
44444413332422111
11111111111111111
22222222222222121
SECOND YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

Page 27
MEDICINE & ALLIED
21
Haemodialysis Upper G.I. Endoscopy Lower G.I. Endoscopy Bronchoscopy Abdominal Ultrasound Exercise Tolerence Test
Echocardiography CT Scan Head EEG EMG/NCS Chest Intubation Pericardiocentesis MRI Brain and Spine CT Scan
Head,Chest,Abdomen Depression and anxiety
211111111111111
111111111111111
211111111111111
1-1-11111111111
212122222222222
SECOND YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

Page 28
MEDICINE & ALLIED
22
Thromvolysis in acute MI Management of Arrythmias - Drug / Defibrillation ECG recordings and reporting ETT ECHO CPR
Pleural Aspiration Pleural Biopsy Chest intubation Broncoscopy Pulmonary function test Blood gases interpertation
CT Scan interpretation MRI interpretation EEG interpretation EMG interpretation
1,2,3 1,2,3 1,2,3
1,2 11,2
1,2,3
1 1 1 11,2
1,2,3 1,2,3
11
646242
311222
4211
CARDIOLOGY (two month rotation)
PULMONOLGY (two month rotation)
NEUROLOGY (two month rotation)

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MEDICINE & ALLIED
23
Peritonial Aspiration Liver Biopsy Upper GI Endoscopy Colonoscopy / sigmoidoscopy V
ariceal banding / Sclerothrepy
Chemeotherapy Radiotherapy
Haemodialysis Renal Biopsy Insertion of double lumen catheter
1,2,3
1111
1,2 1
1,2,3
1,2 1,2
32222
42
422
GASTROENTEROLOGY (two month rotation)
MEDICAL ONCOLOGY (two month rotation)
NEPHROLOGY (two month rotation)

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211121
1,2 1,2 1 11,2 1,2
20 10 10 1 510
Routine Haematology Haemoglobinopathies Coagulation disorders Stem cell transplantation Malignant hematology Blood transfusion
CLINICAL HEMA
TOLOGY (two month rotation
)

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Psoriasis Scabies HS Purpura Erythema Nodosum Fixed Drug Eruption
DERMA
TOLOGY

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SYLLABUS
Cardiology
• Preventive Cardiology
• Coronary Heart Disease
• Acute Rheumatic Fever
• Rheumatic Heart Disease
• Valvular Heart disease
• Infective Endocarditis
• Dizziness/ Syncope and Palpitation
• Arrythmias
• Haemodynamic disturbances
• Hypotension and shock
• CPR, Basic Life Support,
• Advanced Cardiac Life Support
• Heart Failure
• Myocardiditis Cardiomyopathies
• Pericarditis
• Hypertension
Pulmonology
• Prevention of Respiratory diseases
• Cough, Haemoptysis, Dyspnoea
• Pneumonias, Lung abscess
• Bronchiectasis
• Bronchial Asthma
• COPD
• Pulmonary Tuberculosis
• Pleural Effusion
• Pneumothorax
• Lung Cancer
• Interstitial Lung disease and fibrosis
• DVT/ Pulmonary embolism
• Oxygen therapy
• Assisted ventilation
Medical Oncology Including Hematology
• Anemias
• Haemoglobinopathies
• Neutropenia, Neutropenic sepsis

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• Bone Marrow failure
• Transfusion of blood products
• Leukemia
• Lymphomas other myeloproliferative disorders
• Multiple myeloma
• Disorders of Hemostasis
• Platelet disorders, DIC
• Bleeding disorders
• Hypercoagilable state
• Anticoagulation
• Prevention of cancer, staging of cancer
• Oncological emergencies
• Hypercalcemia
• Malignant effusions
GI Tract and Liver
• Nausea, vomiting
• Hiccup, Dyspepsia
• GERD, Dysphagia
• Upper GI bleed
• Oesophageal varices
• Gastritis, NSAID Gastritis
• Peptic ulcer disease
• Diarrhea, Malabsorption syndrome
• Coelic disease
• Irritable bowel disease
• Inflammatory bowel disease
• Constipation
• Antibiotic associated colitis
• Lower GI and rectal bleed
• Abdominal distension
• Jaundice, Acute Hepatitis
• Chronic Hepatitis, Chronic liver disease
• Portal Hypertension
• Decompensated Cirrhosis
• Encephlopathy
• Fulminant liver failure

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Neurology
• Headache, Facial pain
• Meningitis, Encephalitis
• Brain abscess, Epilepsy
• Intracranial space occupying lesions
• Benign intracranial hypertension
• Raised intracranial pressure
• TIAs, Stroke, weakness and paralysis
• Sub-arachnoid hemorrhage
• Coma
• Parkinsonism, other movement disorders
• Spasticity
• Dementia, Multiple sclerosis
• Polyneuropathy
• Motor neuron diseases
• Subacute combined degeneration of spinal cord
• Disorders of neuromuscular transmission
• Myopathies, Periodic paralysis
Nephrology
• Acute Renal Failure
• Chronic Renal Failure
• Glomerulopathies
• Nephrotic Syndrome, Proteinuria
• Haematuria
• Urinary infections
• Cystic diseases of kidney
• Tubulointerstitial diseases
• Multisystem diseases with kidney involvement
• Renal replacement therapy
• Hypertension and kidney
Endocrinology, Diabetes Mellitus, Lipid Disorders
• Diabetes Mellitus
• Diabetic Coma
• The hypoglycemic state
• Diseases of Hypothalmus, Pituitary gland
• Disorders of thyroid and parathyroid glands
• Adrenocortical deficiency
• Cushing Syndrome

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• Clinical uses of corticosteroids
• Dyslipidemias
• Metabolic bone disease
Fluid, Electrolytes, Acid Base Disorders and Poisoning
• Hypo and hyper natremia
• Hypo and hyper kalemia
• Hypo and hyper calcemia
• Acid Base Disorders
• Hyperosmolar Disorders
• Anion gap
• Fluid management
• Poisoning: Salicylates, Tricyclics
• Benzodiazepam, Narcotics
• Paracetamol
• Organophosphorous compounds
Infections, Disorders due to Physical agents and Environment
• Fever of unknown origin
• Sepsis syndrome
• Infections in immune compromised host
• Nosocomial infections
• Infections due to resistant organisms, MRSA, Mycobacterium
• Emerging Infections
o Ebola Virus
o SARS
o MERS
o Congo Crimean Hemorrhagic Fever
o Dengue Fever
o Nigleria Fowleri
• HIV, AIDS
• Sexually transmitted diseases
• Infections in drug users
• Food poisoning
• Acute Infectious diarrhea
• Bacillary dysentery
• Typhoid and Paratyphoid fevers
• Malaria
• Giardiasis
• Amoebiasis
• Leishmaniasis

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• Toxoplasmosis
• Helminthic infections
• Viral diseases
• Rabies
• Ricketsial diseases
• Fungal diseases
• Bacterial diseases
• Chlamydial and spirochetal diseases
• Antibiotics, antiviral drugs, anti fungal drugs,
• Anti tuberculous drugs, Drug reaction, Desensitisation
• Disorders due to Physical agents and environment
• Effects of heat and cold
• Electric shock
• Drowning
• Insect bite, snake bite
• Carbon monoxide poisoning
Dermatology
• Psoriasis
• Scabies
• HS Purpura
• Erythema Nodosum
• Fixed Drug Eruption
Musculoskeletal, Allergic and Immunological Disorders
• Degenerative and crystal induced arthopathies
• Osteoporosis
• Osteoarthritis
• Autoimmune diseases
- SLE
- Scleroderma
- Polymyositis, Dermatomyositis
- Polymyalgia Rheumatica
• Monoarthritis, Infective arthritis, Polyarthritis
• Seronegative spondyloarthritides
• Rheumatoid Arthritis and its variants
• Atopic disorders
• Anaphylaxis, urticaria, angioedema
• Immunodeficiency disorders
• Immunosupressives / immunomodulating therapies
Page 1

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INTERMEDIATE MODULE
IN
MEDICINE & ALLIED
REQUIREMENTS FOR TRAINING & EXAMINATION

Page 5
THIS IS AN EVOLVING DOCUMENT
The College of Physicians and Surgeons Pakistan
would appreciate any criticism, suggestions, advice from the
readers and users of this document. Comments may be sent in
writing or by e-mail to the CPSP at:
DIRECTORATE OF NATIONAL RESIDENCY PROGRAM (DNRP)
College of Physicians and Surgeons Pakistan (CPSP)
7th Central Street, Defence Housing Authority, Karachi-75500.
[email protected]

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01 Introduction
03 Training and Examination
07 Assessment
25 Syllabus
CONTENTS
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The College was established in 1962 through an ordinance of
the Federal Government. The objectives and functions of the
College include: promotion of specialist practice by securing
improvement of teaching and training; arranging postgraduate
medical, surgical and other specialist training; holding and
conducting examinations for awarding College diplomas and
admission to the Fellowships of the College.
Since its inception, the College has taken great strides in
improving postgraduate medical and dental education in
Pakistan. Competency-based structured Residency Programs
have now been developed, along with criteria for accreditation
of training institutions, and for the appointment of supervisors
and examiners. The format of examinations has evolved over
the years to achieve greater objectivity and reliability in
methods of assessment. The recognition of the standards of
College qualifications nationally and internationally,
particularly of its Fellowship, has enormously increased the
number of trainees, and consequently the number of training
institutions and the supervisors. The rapid increase in
knowledge base of medical sciences and consequent
emergence of new subspecialties have gradually increased the
number of CPSP fellowship disciplines to seventy three.
After completing two years of core training during IMM, the
trainees are allowed to proceed to the advance phase of
FCPS training in the specific specialty of choice for 2-3 years.
However, it is mandatory to qualify IMM examination before
taking the FCPS-II exit examination. The work performed by the
trainee is to be recorded in the e-Iog book on daily basis. The
purpose of the e-Iog is to ensure that the entries are made on a
regular basis and to avoid belated and fabricated entries. It will
hence promote accuracy, authenticity and vigilance on the part
of trainees and the supervisors.
INTRODUCTION
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The average number of candidates taking CPSP examinations
each year around 23,000. The College conducts examinations
for FCPS I (11 groups of disciplines), IMM, FCPS II (73
disciplines), MCPS (22 disciplines), including MCPS in HPE and
MCPS in HCSM. A large number of Fellows and senior medical
teachers from within the country and overseas are involved
at various levels of examinations of the College. The College,
in its endeavor to decrease inter-rater variability and increase
fairness and transparency, is using TOACS (Task Oriented
Assessment of Clinical Skills) in IMM and FCPS-II Clinical
examinations. Inclusion of foreign examiners adds to the
credibility of its qualifications at an international level.
It is important to note that in the overall scenario of health
delivery over 85% of the total functioning and registered health
care specialists of the country have been provided by the CPSP.
To coordinate training and examination, and provide assistance
to the candidates stationed in cities other than Karachi, the
College has established 14 Regional Centers (including five
Provincial Headquarter Centers) in the country. The five
Provincial Headquarter Centers, in addition to organizing the
capacity building workshops/short courses also have facilities
of libraries, I.T, and evaluation of synopses and dissertations
along with providing guidance to the candidates in conducting
their research work.
The training towards Fellowship can be undertaken in more than
192 accredited medical institutions throughout the country
and 86 accredited institutions abroad. The total number of
trainees in these institutions is over 17860, who are completing
residency programs with around 3190 supervisors. These
continuous efforts of the College have even more importantly
developed a credible system of postgraduate medical
education for the country. The College strives to make its
courses and training programs ‘evidence’ and needs ‘based’
so as to meet international standards as well as to cater to the
specialist healthcare needs not only for this country but also for
the entire region.
Prof. Zafar Ullah Chaudhry
President
College of Physicians and Surgeons Pakistan

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GENERAL REGULATIONS
Candidate will be admitted to the examination in the name
(surname and other names) as given in the MBBS degree and
PMDC certificate. CPSP will not entertain any application for
change of name on the basis of marriage / divorce /deed.
REGISTRATION AND SUPERVISION
All training must be supervised, and trainees are required to
register with the Registration and Research Cell (R&RC) within
30 days of starting their training for the Intermediate Module.
In case of delay in registration, the start of training will be
considered from the date of receipt of application by the R&RC.
Registration forms are available in R&RC and in the Regional
Centers. They can also be downloaded from the CPSP Website.
Training is compulsorily monitored by an approved supervisor
who is a CPSP fellow or a specialist with relevant postgraduate
qualifications registered at the R&RC. The trainees are not
allowed to work simultaneously in any other department/
institutions for financial benefit and/or for other academic
qualifications
APPROVED TRAINING CENTRES
Training must be undertaken in units, departments and
institutions approved by the College. A current list of approved
institutions is available from the College and its Regional
Centres as well as on the College website: www.cpsp.edu.pk
INDUCTION
As per, CPSP Notification No. CPSP/Secy/2013{20-A) dated
September 24, 2013:
Candidates are required to specify at the time of registration,
whether they will pursue straight fellowship in General
Medicine or would like to join group A or B in Intermediate
Module (IMM),which comprise of:
REGULATIONS
TRAINING AND
EXAMINATION
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GROUP A
GROUP B
• Cardiology
• Cardiology
• Pulmonology
• Dermatology
• Nephrology
• Gastroenterology
• Neurology
• Medical Oncology
• Clinical Heamatology • Clinical Heamatology
Candidates will be eligible to pursue Post-IMM(FCPS II) training
in any of the specialty of the opted group(A/B), subject to
availability of residency slot in an accredited institution.
No change of group is allowed after induction.
DURATION
The duration of training for the Intermediate Module (IMM)
is two (2) years; and residents become eligible to appear in
Intermediate Module examination upon completion of IMM
training.
ROTATIONS
• The trainees in straight fellowship in General Medicine
shall do rotations of 02 months each in four of the
following specialties: Cardiology, (mandatory)
Dermatology, Gastroenterology, Medical Oncology,
Nephrology, Neurology and Pulmonology.
• The trainees in groups A and B will complete rotations
of 02 months in cardiology & any other three specialties
included in the opted group.
COMPONENTS OF TRAINING
Mandatory Workshops
It is mandatory for all trainees to attend the following CPSP
certified workshops/course in the first year of training:
1. Introduction to Computer and Internet
2. Research Methodology and Dissertation Writing
3. Communication Skills
4. Basic Life Support (BLS) Course
Any other workshop/s as may be introduced by the CPSP.

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NOTE: 1) The workshops are conducted by the Department
of Medical Education and the candidates are advised to get
registered online. The BLS course is conducted by the Advanced
Skills Department (ASD) and the registration form is to be
submitted with the ASD separately.
2) No candidate will be allowed to appear in IMM examination
without attending the abovementioned workshops and BLS
course.
E-logbook
The CPSP council has made e-logbook system mandatory
for trainees of all residency programs inducted from July
2011. Upon registration with RTMC each trainee is allotted a
registration number and a password to log on to the e-logbook
on the CPSP website. The trainee is required to enter all work
performed and the academic activities undertaken in the
logbook on daily basis. The concerned supervisor is required
to verify the entries made by the trainee. This system ensures
timely entries by the trainee and prompt verification by the
supervisor. It also helps in monitoring the progress of trainees
and vigilance of supervisors.
Work place based assessment tools like Mini CEX and DOPS are
being developed. Once they are developed, the trainees will
be required to undergo these formative assessment tools and
make their entries in the e-logbook to document attainment of
of competence.
Research (Dissertation / Two Papers)
One of the training requirements for fellowship trainee is a
dissertation or two research papers on a topic related to the
field of specialization. For trainees of straight fellowship
program in General Medicine the synopsis of dissertation or
research papers must be submitted to the Registration and
Research Cell (R&RC) in the first year of the Intermediate
Module. Trainees going to subspecialty (Group A&B) must
submit the synopsis in first year of training of the subspecialty
(i.e. 3rd year of FCPS training).

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Training Progression
Training should incorporate the principle of gradually
increasing responsibility, and provide each trainee with a
sufficient scope, volume and variety of experience in a range
of settings that include inpatients, outpatients, emergency and
intensive care.
Instructional Methodology
Teaching occurs using several methods that range from formal
lectures to planned clinical experiences. The learning domains
include knowledge, skills, attitudes and practices relevant to
the discipline. College of Physicians and Surgeons Pakistan has
developed its own competency model as under:
In order to achieve the competencies of CPSP model, all
curriculum components including instructional methods should
be appropriately aligned to competency network.
The theoretical part of the curriculum presents the current body
of knowledge necessary for practice. This can be imparted using
lectures, grand teaching rounds, clinico-pathological meetings,
morbidity/mortality review meetings, literature reviews and
presentations, journal clubs, self directed learning, conferences
and seminars.
Clinical learning is organized to provide appropriate expertise
and competence necessary to evaluate and manage common
clinical problems. Demonstration in outpatient clinics and
wards and procedural skill training on simulators, manikins and
patients are all practical training modalities.

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7
ASSESSMENT
ELIGIBILITY REQUIREMENTS
For appearing in Intermediate Module examination a candidate
should have:
• Passed FCPS I in Medicine and Allied or granted exemption.
• Registered with the Registration &Research Cell (R&RC).
Completed two years of training under an approved
supervisor in an institution recognized by CPSP. A
certificate of completion of training must be submitted.
• Completed entries in e-logbook along with validation by
the supervisor.
• Submitted certificates of attendance of mandatory
workshops.
• Should have submitted synopsis of dissertation or research
articles.
EXAMINATION SCHEDULE
• The Intermediate Module theory examination will be held
twice a year.
• English shall be the medium of all examinations for theory
and TOACS.
• Theory examinations are held in various cities of the
country usually at Abbottabad, Bahawalpur, Faisalabad,
Hyderabad, Islamabad, Karachi, Nawabshah, Larkana,
Lahore, Multan, Peshawar and Quetta centres. The College
shall decide where to hold TOACS examinations depending
on the number of candidates in a city and shall inform the
candidates accordingly.
• The College will notify of any change in the centres, the
dates and format of the examination.
• A competent authority appointed by the College has the
power to debar any candidate from any examination if it is
satisfied that the candidate has indulged in unfair
practices in College examination, misconduct or because
of any other disciplinary reason.

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8
EXAMINATION FEES
• Fee deposited for a particular examination shall not be
carried over to the next examination in case of withdrawal,
absence or exclusion.
• Applications along with the prescribed examination fee
and required documents must be submitted by the last
date notified for this purpose before each examination.
• The details of examination fee and fee for change of
centre, subject, etc shall be notified before each
examination.
REFUND OF FEES
If after submitting an application for examination, a candidate
decides not to appear, a written request for a refund must be
submitted before the last date for withdrawal with the receipt
of applications. In such cases a refund is admissible to the
extent of 75% of fees only. No request for refund will be accepted
after the closing date for receipt of applications for refund.
If an application is rejected by the CPSP, 75% of the
examination fee will be refunded, the remaining 25% being
retained as a processing charge. No refund will be made for fees
paid for any other reason, e.g. late fee, change of centre/subject
fee, etc.
FORMAT OF EXAMINATION
Intermediate Module examination consists of the following two
components:
Theory Examination:
Theory examination consists of:
Paper I: 100 Single Best Answer type of MCQs
Paper II : 160 Single Best Answer type of MCQs, out of which
the candidate has to attempt 100 MCQs. The details of which
are given below:
• Paper I will be common for all trainees and shall cover
the course content comprising Principles and Practice of
Medicine.
• Paper II shall consist of two sections.

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9
Section A will be mandatory for all trainees and will
consist of 40 MCQs of General Medicine and Cardiology.
Section B will have 120 MCQs, in six blocks with 20
MCQs in each block. Candidates will be required to
attempt any three blocks of their choice (60 MCQs).
Clinical Examination
To test basic clinical skills, the clinical examination consists of:
TOACS (Task Oriented Assessment of Clinical Skills)
TOACS
TOACS will comprise of 12 to 20 stations with a minimum
duration of 6 minutes and change over time of one minute for
the candidate to move from one station to the other.
TOACS shall be same for all trainees and shall be based on core
competencies covering basic clinical and procedural skills,life
supporting skills and communication skills. It will also include
one station on research synopsis and other on e-log. There
will be two types of stations: static and interactive. On
static stations the candidate will be presented with patient data,
a clinical problem or a research study and will be asked to give
written responses about the questions asked. At the interactive
stations the candidate will have to demonstrate a competency,
for example, taking history, performing a clinical examination,
counseling. One examiner will be present at each interactive
station and will either rate the performance of the candidate or
ask questions testing reasoning and problem solving skills.
College is encouraging to have all stations to be interactive and
expects that the static stations will soon be phased out.
Candidates have to pass the theory to be eligible to sit the
TOACS examination.

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CURRICULUM FOR BASIC MEDICAL TRAINING
GOALS
The curriculum of frst two years in medicine involves balanced
and objective integration of basic medical sciences and
essential core clinical knowledge in medicine. The trainee
should be able to diagnose and manage uncomplicated
conditions prevalent in the region and also recognize, stabilize
and refer complicated cases to appropriate place / person.
Upon completion of training in intermediate module in
Medicine and allied, a resident must acquire the basic
competencies in the principles and practice of Medicine along
with outcomes in the domains of knowledge, skills and attitude
in order to:
• Provide appropriate and cost-effective care to patients at
all levels.
• Promote health and prevent disease in patients, families
and communities.
• Practice continuing professional development.
For this purpose the trainee must acquire:
• Knowledge and expertise in clinical and procedural
management of relevant diseases.
• Basics skills.
• Effective clinical judgment and decision making in dealing
with health problems using evidence based medicine.
The coverage that each area receives is not indicative of
the relative importance placed on that area in the training
program or in the examination. These are guidelines and not
comprehensive definitive lists. Only minimum levels of
expected competence have been identified but sufficient scope,
volume and variety of experience are desirable.
 Page 17
MEDICINE & ALLIED
11
EXIT OUTCOMES
By the end of second year of training in Medicine the trainee
should be able to:
a) Assess symptoms and signs
b) Formulate a differential diagnosis
c) Select appropriate investigations and accurately interpret
d) Communicate the diagnosis and prognosis
e) Institute appropriate treatment of the following clinical
conditions recognizing indications, contraindications and side
effects:
• Breathlessness
• Lethargy
• Weight gain/loss
• Nausea/Vomiting
• Pressure sores etc
CORE COMPETENCIES
The core competencies a trainee is expected to acquire at the
end of two years of training and before appearing in
Intermediate Module Examination are aligned to the CPSP
competency frame work mentioned earlier and include:
History Taking
• Understand the symptomatology and recognize alarm
symptoms
• Take history in problem situations as when patient’s
language is different from trainee’s language or when
confronted with confused and deaf patients.
• Formulate a differential diagnosis after analysis and
synthesis of identified problems
• Recognize psychological and social issues developing
due to disease or infirmity
• Show empathy with the patient
Physical Examination
• Take permission to examine and explain the procedure
• Elicit signs and use instruments with maximum care
• Comprehend the ethics of privacy and confidentiality and
apply it for individual cases
• Recognize the role of and seek help of attendants/relatives
where required

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Medical Record Keeping
• Record accurately patient’s history, examination,
differential diagnosis, investigations and management
plan
• Fill in all the required hospital record forms accurately
• Maintain records with dates and sign each entry
• Ensure that notes are accessible to all members of the
team and patients /relatives (if required)
• Use latest technology for the benefit of patient e.g. fax,
email etc
Time Management
• Set priorities for tasks to be accomplished
• Plan line of action while keeping realistic expectations of
tasks to be completed by self and others
Decision Making
• Analyze and synthesize clinical problems
• Recognize the role of and consult other members of the
health care team
• Approach tasks with flexibility
Basic Life Support
• Examine and assess a collapsed patient
• Maintain adequate airway and perform effective
cardiopulmonary resuscitation
• Control one’s own emotions and enable others to keep
calm
Communication Skills
• Use open ended questions for gaining information
• Communicate effectively with patients taking care of their
level of understanding
• Encourage questions from the patients and their relatives
• Avoid technical terms
• Use interpreters where necessary
• Provide information to patients in simple and precise
language
• Give due respect to patients and their relatives and
share information when appropriate

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• While counseling give choices and help the patient in
decision making
• Show empathy and concern during breaking bad news
• Avoid conveying unrealistic optimism
• Discuss ethics, medical procedure & legal implications
related to organ donation with the patient and their
relatives when required
Life Long Learning
• Pursue professional development activities/ programs
• Understand the role of appraisal and of assessment
• Recognize and make full use of learning opportunities
• Make effort to learn from seniors, colleagues and others
• Demonstrate proficiency in the use of information
technology
Practice Evidence Based Medicine
• Show competence in use of all sources of information e.g.
databases as Medline, library and the internet
• Use evidence to support patient care effectively
• Critically evaluate medical evidence using principles of
EBM
Uses Clinical Audit/Guidelines for patient care
• Recognize the relevance of audit to benefit patient care
• Participate in clinical audits
• Comprehend the problems and benefits of existing
guidelines
• Use local guidelines where applied
• Take care of individual patient needs when using
guidelines
Professionalism and Ethics
• Recognize the importance of Informed consent and
practice it in a manner that the patient is able to
understand it fully
• Respect the right to confidentiality
• Maintain patient’s confidentiality
• Use and share all information with the patient and their

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relatives as and where appropriate
• Partake legal responsibilities of writing Death certificate,
mental health certificate
• Show responsibility in maintaining continuity of care
• Ensure satisfactory completion of delegated tasks by the
end of the shift/day with appropriate handover
• Display non discriminatory attitude towards all the patients
• Refrain from giving unnecessary personal comments
• Exercise care in managing inappropriate behaviour e.g.
aggression, violence, sexual harassment in patients
• Recognize own limitations and accept constructive criticism
• Act as a responsible member of health care team
Patient Education
• Educate patients about: disease, investigations, therapy,
possible alternatives /choices, rehabilitation etc.
• Counsel patients, explaining individual treatment plans
and the actions to be taken if the condition deteriorates or
improves
• Encourage patients to access further information / patient
support groups
Disease Prevention
• Identify role of environmental and lifestyle risk factors,
such as diet, exercise, social deprivation, occupation and
substance abuse in disease causation
• Comprehend the Epidemiology and screening procedures
for risk factors
• Provide support and advice on quitting the use of tobacco/
alcohol etc.
• Assess individual patient’s risk factors
• Encourage participation in appropriate disease prevention
or screening programs
Teaching and Training (Pedagogy)
• Communicate and share information with all members of
health care team
• Adopt Learner-centered approach while teaching/training
• Demonstrate willingness, enthusiasm and patience to
teach

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• Seek feedback from peers as well as from juniors
• Make best use of all teaching opportunities
• Develop effective presentation skills
• Use effectively multiple audio-visual aids for presentation
Safe Management while on Call
• Recognize medical indications for urgent investigations
and therapy
• Identify skills and competencies of other members of the
‘on- call ‘ team
• Prioritize the tasks to be carried out
• Call for help and refer the case whenever required
• Effectively interact with other health care professionals
• Keep patients and relatives informed
• Hand over all the information to the proceeding team staff
safely
Discharge Planning
• Recognize the impact of unnecessary hospitalization
• Educate the patient and relatives regarding impact of
physical problems on daily activities
• Liaise and communicate with patient, family and primary
care services
• Write reports for appropriate bodies
Resuscitation and Advanced Cardiac Life Support
• Recognize critically ill patients.
• Practice Advanced cardiac life support algorithms
• Recognize cardiac arrhythmias
• Manage patients on commonly used anti arrhythmic and
cardiac support drugs
• Perform emergency defibrillation
• Lead a cardiac arrest team
• Understand Legal and ethical considerations regarding; Do
not resuscitate orders (DNR)
• Act with empathy and sensitivity while dealing with
patients and families

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Nutrition
• Identify impact of disease on nutritional status and
malnutrition on clinical outcomes
• Assess nutritional status of patients
• Recognize cultural and religious issues
• Utilize proper routes of nutrition support
• Refer cases to nutritionist when required

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PROCEDURAL COMPETENCIES
The clinical competencies, a specialist must have, are varied
and complex. A complete list of the procedures and skills
for trainees is given below. The level of competence to be
achieved each year is specified according to the key, as follows:
1. Observer status
2. Assistant status
3. Performed under supervision
4. Performed independently

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Pleural Aspiration Peritoneal Aspiration Lumbar puncture Nasogastric Intubation Uretheral catheterization Recording and reporting ECG
Proctoscopy Endotracheal Intubation Cardio-Pulmonary Resuscitation (CPR) Insertion of CVP lines Arterial puncture Urine
Examination Liver biopsy Pleural biopsy Joint aspiration Bone marrow aspiration Renal biopsy
1,2 1,2 11,2 1,2 1 - 11,2 1 - 3 1 - - - -
222225-111-11----
3323321232-321-1-
4434431333-322111
2222251222-111111
44444413331322111
22222511222111-11
8 8 8 8 8 20 3 6 6 6 2 4 4 3 1 3 2
2222251211-111-1-
FIRST YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

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Haemodialysis Upper G.I. Endoscopy Lower G.I. Endoscopy Bronchoscopy Abdominal Ultrasound Exercise Tolerence Test
Echocardiography CT Scan Head,Chest,Abdomen EEG EMG/NCS Chest Intubation Pericardiocentesis MRI Brain
-------------
-------------
1------1-----
11-11-11----1
11-11-11----1
21111-11----1
11111-11----1
32122-23----2
1------1-----
FIRST YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

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Pleural Aspiration Peritoneal Aspiration Lumbar puncture Nasogastric Intubation Uretheral catheterization Recording and reporting ECG
Proctoscopy Endotracheal Intubation (Cardio-Pulmonary Resuscitation (CPR Insertion of CVP lines Arterial puncture Urine
Examination Liver biopsy Pleural biopsy Joint aspiration Bone marrow aspiration Renal biopsy
44444413332422111
11111111111111-1-
44444413332422111
11111111111111111
22222222222222121
SECOND YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

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Haemodialysis Upper G.I. Endoscopy Lower G.I. Endoscopy Bronchoscopy Abdominal Ultrasound Exercise Tolerence Test
Echocardiography CT Scan Head EEG EMG/NCS Chest Intubation Pericardiocentesis MRI Brain and Spine CT Scan
Head,Chest,Abdomen Depression and anxiety
211111111111111
111111111111111
211111111111111
1-1-11111111111
212122222222222
SECOND YEAR
Total Cases
First Year
Rotations to be incorporated as and when available with the
consent of respected supervisor

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Thromvolysis in acute MI Management of Arrythmias - Drug / Defibrillation ECG recordings and reporting ETT ECHO CPR
Pleural Aspiration Pleural Biopsy Chest intubation Broncoscopy Pulmonary function test Blood gases interpertation
CT Scan interpretation MRI interpretation EEG interpretation EMG interpretation
1,2,3 1,2,3 1,2,3
1,2 11,2
1,2,3
1 1 1 11,2
1,2,3 1,2,3
11
646242
311222
4211
CARDIOLOGY (two month rotation)
PULMONOLGY (two month rotation)
NEUROLOGY (two month rotation)

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Peritonial Aspiration Liver Biopsy Upper GI Endoscopy Colonoscopy / sigmoidoscopy V
ariceal banding / Sclerothrepy
Chemeotherapy Radiotherapy
Haemodialysis Renal Biopsy Insertion of double lumen catheter
1,2,3
1111
1,2 1
1,2,3
1,2 1,2
32222
42
422
GASTROENTEROLOGY (two month rotation)
MEDICAL ONCOLOGY (two month rotation)
NEPHROLOGY (two month rotation)

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211121
1,2 1,2 1 11,2 1,2
20 10 10 1 510
Routine Haematology Haemoglobinopathies Coagulation disorders Stem cell transplantation Malignant hematology Blood transfusion
CLINICAL HEMA
TOLOGY (two month rotation
)
 Page 31
MEDICINE & ALLIED
25
Psoriasis Scabies HS Purpura Erythema Nodosum Fixed Drug Eruption
DERMA
TOLOGY

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SYLLABUS
Cardiology
• Preventive Cardiology
• Coronary Heart Disease
• Acute Rheumatic Fever
• Rheumatic Heart Disease
• Valvular Heart disease
• Infective Endocarditis
• Dizziness/ Syncope and Palpitation
• Arrythmias
• Haemodynamic disturbances
• Hypotension and shock
• CPR, Basic Life Support,
• Advanced Cardiac Life Support
• Heart Failure
• Myocardiditis Cardiomyopathies
• Pericarditis
• Hypertension
Pulmonology
• Prevention of Respiratory diseases
• Cough, Haemoptysis, Dyspnoea
• Pneumonias, Lung abscess
• Bronchiectasis
• Bronchial Asthma
• COPD
• Pulmonary Tuberculosis
• Pleural Effusion
• Pneumothorax
• Lung Cancer
• Interstitial Lung disease and fibrosis
• DVT/ Pulmonary embolism
• Oxygen therapy
• Assisted ventilation
Medical Oncology Including Hematology
• Anemias
• Haemoglobinopathies
• Neutropenia, Neutropenic sepsis

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• Bone Marrow failure
• Transfusion of blood products
• Leukemia
• Lymphomas other myeloproliferative disorders
• Multiple myeloma
• Disorders of Hemostasis
• Platelet disorders, DIC
• Bleeding disorders
• Hypercoagilable state
• Anticoagulation
• Prevention of cancer, staging of cancer
• Oncological emergencies
• Hypercalcemia
• Malignant effusions
GI Tract and Liver
• Nausea, vomiting
• Hiccup, Dyspepsia
• GERD, Dysphagia
• Upper GI bleed
• Oesophageal varices
• Gastritis, NSAID Gastritis
• Peptic ulcer disease
• Diarrhea, Malabsorption syndrome
• Coelic disease
• Irritable bowel disease
• Inflammatory bowel disease
• Constipation
• Antibiotic associated colitis
• Lower GI and rectal bleed
• Abdominal distension
• Jaundice, Acute Hepatitis
• Chronic Hepatitis, Chronic liver disease
• Portal Hypertension
• Decompensated Cirrhosis
• Encephlopathy
• Fulminant liver failure

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Neurology
• Headache, Facial pain
• Meningitis, Encephalitis
• Brain abscess, Epilepsy
• Intracranial space occupying lesions
• Benign intracranial hypertension
• Raised intracranial pressure
• TIAs, Stroke, weakness and paralysis
• Sub-arachnoid hemorrhage
• Coma
• Parkinsonism, other movement disorders
• Spasticity
• Dementia, Multiple sclerosis
• Polyneuropathy
• Motor neuron diseases
• Subacute combined degeneration of spinal cord
• Disorders of neuromuscular transmission
• Myopathies, Periodic paralysis
Nephrology
• Acute Renal Failure
• Chronic Renal Failure
• Glomerulopathies
• Nephrotic Syndrome, Proteinuria
• Haematuria
• Urinary infections
• Cystic diseases of kidney
• Tubulointerstitial diseases
• Multisystem diseases with kidney involvement
• Renal replacement therapy
• Hypertension and kidney
Endocrinology, Diabetes Mellitus, Lipid Disorders
• Diabetes Mellitus
• Diabetic Coma
• The hypoglycemic state
• Diseases of Hypothalmus, Pituitary gland
• Disorders of thyroid and parathyroid glands
• Adrenocortical deficiency
• Cushing Syndrome

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• Clinical uses of corticosteroids
• Dyslipidemias
• Metabolic bone disease
Fluid, Electrolytes, Acid Base Disorders and Poisoning
• Hypo and hyper natremia
• Hypo and hyper kalemia
• Hypo and hyper calcemia
• Acid Base Disorders
• Hyperosmolar Disorders
• Anion gap
• Fluid management
• Poisoning: Salicylates, Tricyclics
• Benzodiazepam, Narcotics
• Paracetamol
• Organophosphorous compounds
Infections, Disorders due to Physical agents and Environment
• Fever of unknown origin
• Sepsis syndrome
• Infections in immune compromised host
• Nosocomial infections
• Infections due to resistant organisms, MRSA, Mycobacterium
• Emerging Infections
o Ebola Virus
o SARS
o MERS
o Congo Crimean Hemorrhagic Fever
o Dengue Fever
o Nigleria Fowleri
• HIV, AIDS
• Sexually transmitted diseases
• Infections in drug users
• Food poisoning
• Acute Infectious diarrhea
• Bacillary dysentery
• Typhoid and Paratyphoid fevers
• Malaria
• Giardiasis
• Amoebiasis
• Leishmaniasis

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• Toxoplasmosis
• Helminthic infections
• Viral diseases
• Rabies
• Ricketsial diseases
• Fungal diseases
• Bacterial diseases
• Chlamydial and spirochetal diseases
• Antibiotics, antiviral drugs, anti fungal drugs,
• Anti tuberculous drugs, Drug reaction, Desensitisation
• Disorders due to Physical agents and environment
• Effects of heat and cold
• Electric shock
• Drowning
• Insect bite, snake bite
• Carbon monoxide poisoning
Dermatology
• Psoriasis
• Scabies
• HS Purpura
• Erythema Nodosum
• Fixed Drug Eruption
Musculoskeletal, Allergic and Immunological Disorders
• Degenerative and crystal induced arthopathies
• Osteoporosis
• Osteoarthritis
• Autoimmune diseases
- SLE
- Scleroderma
- Polymyositis, Dermatomyositis
- Polymyalgia Rheumatica
• Monoarthritis, Infective arthritis, Polyarthritis
• Seronegative spondyloarthritides
• Rheumatoid Arthritis and its variants
• Atopic disorders
• Anaphylaxis, urticaria, angioedema
• Immunodeficiency disorders
• Immunosupressives / immunomodulating therapies

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SUGGESTED READING LIST
Standard text book of Medicine such as:
• Haslett C, Chilvers ER, Bom NA eds. Davidson’s Principles
and Practice of Medicine. 19th ed. Edinburgh: Churchill
Livingstone 2002.
• Carpenter CCJ, Griggs RC, Loscalzo J eds. Cecil Essentials
of Medicine.6th ed. Philadelphia: Saunders, 2004.
• Kumar P, Clark M eds. Kumar and Clark Clinical Medicine.
5th ed. Edinburgh: WB Saunders, 2002.
• Munro JF, Campbell IW eds. McLeod’s Clinical Examination.
10th ed. Edinburgh: Churchill Livingstone 2000.
• Swash M. Hutchison’s Clinical Methods.21st ed. London.
Saunders, 2002.
Reference Books:
• Weather DJ. Oxford Text book of Medicine. Oxford
University Press.
• Goldman L. Cecil’s Text Book of Medicine.22nd ed.
Philadelphia: Saunders 2004.
• Braunwald E. Harrison’s Principles of Internal Medicine. 2
vols. 15th ed. New York: McGraw Hill 2004.
Suggested Medical Journals:
1. BMJ (British Medical Journal)
2. NEJM (New England Journal of Medicine)
3. JAMA (Journal of the American Medical Association)
4. The Lancet
5. JCPSP (Journal of College of Physicians and Surgeons
Pakistan)
Medical Website:
www.medscape.com