Medicine and allied is the largest domain in NRE Step I: about 26% of the paper, roughly 52 of 200 items, and PM&DC's blueprint figure for it is legible in the published table. It covers general medicine plus psychiatry, dermatology and neurology. The stems describe Pakistani patients and a Pakistani disease burden, so typhoid (including XDR), tuberculosis, malaria, dengue, CCHF, hepatitis B and C and organophosphate poisoning sit alongside cardiology, respiratory, renal, endocrine and haematology. Spend the largest block of your study time here, and learn local first-line management rather than the first option in an international textbook.
Weight and expected item count
PM&DC's 2024 syllabus gives Medicine and Allied 52 of the 140 clinical items. With surgery at 48, the two domains hold 100 of the 200 questions, so a clinical weakness here cannot be rescued by strong basic sciences. At 63 seconds an item, plan for roughly 55 minutes of the paper in this domain. The syllabus appendix lists 14 sections for medicine: infections, GI and liver, haematology, rheumatology, renal, electrolytes, cardiovascular, respiratory, poisoning, endocrine, CNS, skin and psychiatry.
What is tested
Subtopics below follow the PM&DC syllabus structure as we have read it. Stems usually ask for the most likely diagnosis, the next best step, the drug of choice or the complication.
| Block | Topics |
|---|---|
| Infectious disease | Typhoid including XDR Salmonella Typhi; pulmonary and extrapulmonary TB, MDR and XDR-TB; malaria (vivax, falciparum, severe); dengue and fluid management; CCHF and other zoonoses; HIV and sepsis |
| Liver and GI | Viral hepatitis B and C, cirrhosis, hepatocellular carcinoma; peptic ulcer, GI bleeding, inflammatory bowel disease; chronic liver disease, hepatic encephalopathy, pancreatitis |
| Cardiovascular | Acute coronary syndrome and ischaemic heart disease; heart failure and cardiomyopathy; rheumatic heart disease and valve disease; arrhythmias and hypertension |
| Respiratory | Pneumonia, COPD, asthma, pulmonary embolism; interstitial lung disease and lung cancer |
| Renal and electrolytes | CKD, AKI, nephrotic and nephritic syndromes; electrolyte and acid-base disorders |
| Endocrine | Diabetes mellitus, DKA, hypoglycaemia; thyroid, adrenal and pituitary disorders |
| Haematology and rheumatology | Anaemias, thalassaemia, leukaemias, bleeding disorders; rheumatoid arthritis, SLE and vasculitis |
| Neurology, psychiatry, skin, poisoning | Stroke, epilepsy, meningitis, neuromuscular disease; common psychiatric disorders and emergencies; leishmaniasis and scabies; organophosphate and other poisonings |
Local guideline points
- XDR typhoid: since the 2016 Hyderabad outbreak, Salmonella Typhi H58 resistant to chloramphenicol, ampicillin, co-trimoxazole, fluoroquinolones and third-generation cephalosporins has been treated with azithromycin or a carbapenem (WHO typhoid fact sheet).
- Tuberculosis: 2HRZE then 4HR for drug-susceptible TB; WHO-endorsed four-month regimens exist for selected groups; GeneXpert is the first test; DOTS is the delivery model.
- Malaria: vivax is the predominant species. Uncomplicated falciparum: artemether-lumefantrine. Vivax: chloroquine plus primaquine after a G6PD check. Severe malaria: intravenous artesunate.
- Dengue: know the warning signs (abdominal pain, persistent vomiting, mucosal bleeding, lethargy, hepatomegaly, rising haematocrit with falling platelets). Use paracetamol; avoid NSAIDs and aspirin.
- CCHF: endemic in Balochistan and Khyber Pakhtunkhwa, tick-borne (Hyalomma) or from animal blood, with a rise around Eid ul Adha; ribavirin is used.
- Hepatitis C: direct-acting antivirals have replaced interferon; the national and provincial hepatitis control programmes offer free screening and treatment. Use WHO guidance for regimens.
- Organophosphate poisoning: atropine titrated to drying of bronchial secretions, plus pralidoxime. Aluminium phosphide has high mortality and no specific antidote.
The fuller fact sheet with sources is in local guidelines you must know.
Three typical traps
- Importing the wrong first-line drug. A curriculum built on another country's resistance pattern may teach a fluoroquinolone or a third-generation cephalosporin for enteric fever. When a Pakistani stem states XDR or a resistance pattern, the textbook default is wrong. Read the culture result before you read the options.
- Treating dengue like a bacterial fever. The stem may describe a patient defervescing with a rising haematocrit and falling platelets. That pattern is the critical phase, where management is careful fluid replacement and monitoring, not antibiotics, NSAIDs or empirical platelet transfusion for a number.
- Answering the diagnosis when the question asks for the next step. In emergencies (ACS, DKA, hyperkalaemia with ECG changes, status epilepticus, severe malaria), the first action is often stabilisation or a bedside treatment before confirmatory tests. Underline the question word before you choose.
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How to revise it
This domain rewards volume with feedback: many questions, each followed by a reasoned explanation. A fixed rhythm works better than a list of chapters.
| Block | Do this | Time |
|---|---|---|
| Pakistani infections | One page per disease: presentation, diagnosis, first-line treatment, complications, prevention. Then 30 questions. | 4 to 5 days |
| Cardiology and respiratory | ACS pathways, heart failure drug classes, rheumatic fever and valves, asthma and COPD ladders. Add ECG and chest X-ray reading. | 5 days |
| GI, liver and renal | Cirrhosis complications, hepatitis serology, GI bleeding, AKI versus CKD, nephrotic versus nephritic, electrolytes. | 5 days |
| Endocrine and haematology | DKA and hypoglycaemia protocols, thyroid and adrenal, anaemia work-up, thalassaemia, leukaemia types. | 4 days |
| Neurology, psychiatry, skin, rheumatology | Stroke syndromes, seizures, meningitis; depression, psychosis and emergencies; leishmaniasis and scabies; RA, SLE. | 5 days |
| Mixed review | Timed blocks of 50 across all blocks; rework your error log. | Ongoing |
Keep one rule: for every wrong answer, write why the correct answer beat your choice. For methods that apply across domains, see the study plan; for a ranking against other domains, see high-yield topics.
Core facts to state without notes
- Acute coronary syndrome: ST elevation with symptoms needs prompt reperfusion; the ECG and troponin guide the rest of the group.
- Diabetic ketoacidosis: start with fluids, then an insulin infusion, with potassium monitored and replaced because it falls once insulin is running.
- Hyperkalaemia: with ECG changes, intravenous calcium gluconate protects the heart, and insulin with glucose shifts potassium into cells.
- Hepatic encephalopathy: look for a precipitant (bleeding, infection, constipation, electrolyte change), and treat with lactulose.
- Ischaemic stroke: a non-contrast CT excludes haemorrhage before thrombolysis, which is time-limited to a few hours from onset.
- Status epilepticus: a benzodiazepine is first-line, with a second-line antiepileptic if seizures continue.
- Rheumatic fever: diagnosed by the Jones criteria; the long-term valve damage is the cause of most rheumatic heart disease seen in adults.
- Nephrotic versus nephritic: heavy proteinuria, hypoalbuminaemia and oedema versus haematuria, hypertension and reduced GFR.
Self-check list
| Can you say, in one sentence each... | Mark |
|---|---|
| The first-line treatment for typhoid, TB, vivax malaria and severe malaria in Pakistan | red, amber or green |
| How you manage a patient with dengue in the critical phase | red, amber or green |
| The complications of cirrhosis and how each is treated | red, amber or green |
| How you interpret a blood gas and an ECG strip | red, amber or green |
| The emergency steps for DKA, hyperkalaemia and status epilepticus | red, amber or green |
Links to other domains
Medicine overlaps most with applied pathology (microbiology, haematology), clinical pharmacology (anti-TB, antimalarial and antiviral drugs) and community medicine (programmes). A fact learned once in this domain often earns marks in all four.
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Frequently asked questions
How many questions are in medicine and allied?
PM&DC's blueprint gives 52 of the 140 clinical items, about 26% of the 200-question paper. It includes psychiatry, dermatology and neurology.
Which infections are tested most?
PM&DC's syllabus names typhoid, TB, malaria and dengue, plus hepatitis B and C, CCHF, HIV and sepsis. The blueprint gives no topic-level frequency, so we rank by weight and local relevance, not by recall.
What is the treatment for XDR typhoid?
Azithromycin or a carbapenem, according to WHO's typhoid fact sheet. The strain is resistant to chloramphenicol, ampicillin, co-trimoxazole, fluoroquinolones and third-generation cephalosporins.
Should I avoid NSAIDs in dengue?
Yes. WHO guidance for dengue advises paracetamol for fever and avoiding NSAIDs and aspirin because of bleeding risk.
Does the exam include psychiatry and dermatology?
Yes, under medicine and allied. The syllabus lists common psychiatric disorders and emergencies and common skin conditions including leishmaniasis and scabies.
How long should I spend on this domain?
About a quarter of your total study time, and the first block in any plan. The 12-week plan gives it roughly three weeks.