Special Thanks To My Beloved Father

“Syed Ashfaq Ali”

For your guidance, strength, and endless inspiration.

“The Family Medicine Casebook: Practical Clinical Scenarios for Everyday Practice”

By

Dr. Syed Aamir Ali Naqvi

Family Physician (Gold Medalist)

Credentialed (PM&DC, MMC)

Member – Pakistan Academy of Family Physicians (PAFP)

M.D. (SSMU, KZ)

ECFMG Regd. (USA)

MCC Certified (Canada)

PGD-FM (SCM, STMU, PK)

PGCert-MHR (GIHD, STMU, PK)

© 2026 Dr. Syed Aamir Ali Naqvi – All Rights Reserved

Table of Contents

⚕️ Scope of Practice — Family Physician

I. General & Administrative

• Patient registration, record keeping, confidentiality, consent, documentation
  
  

• Health screening, preventive check-ups, vaccination
  
  

• Chronic disease follow-up, medication reconciliation
  
  

• Fitness, medical and vaccination certificates
  
  

• Referral documentation, emergency stabilization, medico-legal notes
  
  

II. General Medicine (Adult)

1. Acute illnesses

• Fever, flu, sore throat, tonsillitis, bronchitis, pneumonia (mild–moderate)
  
  

• Gastroenteritis, food poisoning, dyspepsia, GERD
  
  

• Migraine, tension headache, vertigo
  
  

• UTI, cystitis, prostatitis (initial management)
  
  

• Allergies, urticaria, anaphylaxis (stabilize, refer if severe)
  
  

• Poisoning (first aid, antidote, referral)
  
  

2. Chronic conditions

• Hypertension, Diabetes, Dyslipidemia
  
  

• Thyroid disorders
  
  

• Asthma, COPD (stable cases, exacerbations initial care)
  
  

• Chronic kidney disease (stages 1–3)
  
  

• Benign prostatic hyperplasia
  
  

• Arthritis, gout, chronic pain
  
  

• Obesity, metabolic syndrome
  
  

3. Geriatric medicine

• Polypharmacy review
  
  

• Falls, confusion, dementia, frailty
  
  

• Pressure ulcers, chronic wounds
  
  

III. Pediatrics (Children & Infants)

• Growth & development monitoring, nutrition counseling
  
  

• Immunizations (national & travel-related)
  
  

• Fever, respiratory, ear, throat, skin, GI infections
  
  

• Worm infestation, dehydration, anemia
  
  

• Asthma, allergies, eczema
  
  

• Developmental delays (screening & referral)
  
  

• Neonatal jaundice (identify, initial management, refer if severe)
  
  

• Febrile seizures, breath-holding spells
  
  

• School health, behavioral issues (ADHD screening, learning problems)
  
  

IV. Women’s Health / Obstetrics & Gynecology

• Antenatal check-up (normal pregnancy) & referral when high-risk
  
  

• Postnatal follow-up, breastfeeding advice
  
  

• Menstrual disorders: dysmenorrhea, menorrhagia, amenorrhea
  
  

• Vaginal discharge, pelvic pain, UTI
  
  

• Contraception advice & prescriptions
  
  

• Menopause management
  
  

• Breast examination, Pap smear (screening & referral for abnormal findings)
  
  

• Pregnancy testing, counseling, referral for complications
  
  

V. Men’s Health

• Erectile dysfunction, premature ejaculation
  
  

• Infertility (basic work-up, referral)
  
  

• Prostatitis, BPH, LUTS (assessment, initial management)
  
  

• Hypogonadism screening, testosterone deficiency awareness
  
  

VI. Dermatology

• Acne, eczema, psoriasis, fungal, bacterial, viral skin infections
  
  

• Urticaria, drug rash, contact dermatitis
  
  

• Alopecia, dandruff, pigmentation disorders
  
  

• Scabies, lice, nail infections
  
  

• Skin tag/wart removal (if trained & equipped)
  
  

• Suspicious lesions — biopsy or referral for malignancy
  
  

VII. ENT / Eye

ENT:

• Otitis media/externa, wax, sinusitis, allergic rhinitis
  
  

• Sore throat, tonsillitis, pharyngitis
  
  

• Epistaxis (initial control, referral if uncontrolled)
  
  

• Vertigo (BPPV, vestibular neuritis)
  
  

Eye:

• Conjunctivitis, stye, blepharitis
  
  

• Foreign body removal
  
  

• Refractive errors screening
  
  

• Red eye — initial treatment or referral if suspect glaucoma or ulcer
  
  

VIII. Cardiology

• Hypertension (all grades, referral if resistant or crisis)
  
  

• Ischemic heart disease (angina, post-MI follow-up)
  
  

• Palpitations, arrhythmias (ECG interpretation, referral if unstable)
  
  

• Heart failure (stabilize, manage mild cases, refer severe)
  
  

• Peripheral vascular disease
  
  

IX. Respiratory

• Asthma, COPD, bronchitis, pneumonia, tuberculosis (screening, initial therapy)
  
  

• COVID-19, influenza management
  
  

• Occupational lung disease screening
  
  

• Smoking cessation counseling
  
  

X. Gastroenterology

• GERD, peptic ulcer, IBS, constipation, diarrhea, hemorrhoids
  
  

• Hepatitis screening & follow-up (A, B, C)
  
  

• Cholelithiasis, pancreatitis — diagnose, stabilize, refer
  
  

• Malabsorption, fatty liver, obesity counseling
  
  

XI. Nephrology / Urology

• UTI, renal colic, stones (pain relief, hydration, referral if obstructed)
  
  

• CKD screening (urinalysis, eGFR)
  
  

• Proteinuria, hematuria — work-up, referral
  
  

• BPH, prostatitis
  
  

• Catheterization (if trained and indicated)
  
  

XII. Endocrinology

• Diabetes (type 1, type 2, gestational)
  
  

• Thyroid disorders (hypo/hyperthyroidism)
  
  

• Adrenal and pituitary disorders (screening, refer specialized)
  
  

• Obesity, metabolic syndrome, PCOS
  
  

XIII. Neurology

• Headache, migraine, tension, cluster
  
  

• Seizures (stabilize, initiate treatment, refer)
  
  

• Stroke (recognize, stabilize, urgent referral)
  
  

• Neuropathy (diabetic, B12 deficiency)
  
  

• Parkinsonism, tremor, weakness evaluation
  
  

XIV. Psychiatry & Behavioral Health

• Anxiety, depression, stress, insomnia
  
  

• Substance abuse screening, counseling, referral
  
  

• Grief, trauma, marital, family counseling
  
  

• Suicide risk identification & immediate referral
  
  

• ADHD, learning disorders (pediatric screening)
  
  

XV. Orthopedics / Musculoskeletal

• Sprains, strains, tendinitis, back pain
  
  

• Fracture first aid, immobilization, referral
  
  

• Osteoarthritis, rheumatoid arthritis follow-up
  
  

• Sports injuries
  
  

• Gout, bursitis
  
  

XVI. Surgical / Emergency Care

• Minor cuts, burns, lacerations, abscess drainage
  
  

• Wound suturing & dressing
  
  

• Foreign body removal (skin, eye, ear, nose)
  
  

• Epistaxis, tooth extraction (if trained)
  
  

• Shock, dehydration, hypoglycemia management
  
  

• Anaphylaxis, asthma attack stabilization
  
  

• CPR, basic life support
  
  

• Snake bite, dog bite (first aid, antiserum, referral)
  
  

XVII. Infectious Diseases

• Fever of unknown origin (FUO)
  
  

• Dengue, malaria, typhoid, hepatitis, influenza, COVID-19
  
  

• STDs (screening, counseling, initial management)
  
  

• HIV counseling, testing, post-exposure prophylaxis (PEP)
  
  

• Traveler’s health: vaccination, malaria prophylaxis
  
  

XVIII. Preventive & Community Health

• Screening: BP, diabetes, cholesterol, BMI, cancer, anemia
  
  

• Immunization (child, adult, travel, occupational)
  
  

• Health education, smoking cessation, weight management
  
  

• Occupational health, ergonomic counseling
  
  

• Environmental & vector-borne disease awareness
  
  

XIX. Rehabilitation & Chronic Care

• Post-stroke, post-MI, post-fracture rehabilitation
  
  

• Lifestyle modification plans
  
  

• Pain management (non-opioid, non-invasive)
  
  

• Home care advice, caregiver training
  
  

XX. Legal & Ethical Responsibilities

• Documentation and record retention
  
  

• Informed consent & confidentiality
  
  

• MLCs (injury, assault, poisoning) — document and refer
  
  

• Disability & fitness certification (as permitted)
  
  

• Professional boundaries, referral ethics
  
  

• Prescribing legally registered medicines only
  
  

⚖️ Summary of Role

• Diagnose and manage >80% of all primary care conditions
  
  

• Stabilize and refer serious, surgical, or tertiary-level cases
  
  

• Maintain preventive and community health standards
  
  

• Act ethically, document properly, and ensure continuity of care

I. GENERAL & ADMINISTRATIVE

1. Patient Registration & History Taking

• Purpose: Create accurate medical records for continuity of care
  
  

• Steps:
  
  

  • Collect demographics: name, age, gender, contact, ID
    
    

  • Chief complaint, history of presenting illness
    
    

  • Past medical history, surgical history, medications, allergies
    
    

  • Family history, social history (smoking, alcohol, occupation)
    
    

  • Review of systems relevant to presenting complaint
    
    

• Documentation: Ensure legible, complete, and timely entries
  
  

2. Consent & Documentation

• Informed Consent:
  
  

  • Explain diagnosis, procedure, benefits, risks, alternatives
    
    

  • Obtain signature or verbal consent documented in the chart
    
    

• Confidentiality:
  
  

  • Maintain patient privacy per ethical and legal standards
    
    

  • Limit access to authorized personnel only
    
    

3. Maintenance of Medical Records

• Keep records updated, organized, and secure
  
  

• Use electronic medical records (EMR) or structured paper charts
  
  

• Include lab results, prescriptions, imaging reports, and follow-ups
  
  

4. Preventive Health Checkups & Annual Screenings

• Adults: BP, BMI, blood glucose, lipid profile, cancer screening (breast, cervical, colon)
  
  

• Children: Growth monitoring, developmental milestones, anemia screening
  
  

• Document results, provide counseling, and schedule follow-ups
  
  

5. Vaccination Services & Travel Medicine Advice

• Routine immunizations per national schedule
  
  

• Travel vaccines based on destination risk (e.g., yellow fever, hepatitis A/B, typhoid)
  
  

• Counsel on vaccine side effects and timing
  
  

6. Chronic Disease Follow-Up & Medication Review

• Regular review of patients with hypertension, diabetes, asthma, etc.
  
  

• Check adherence, efficacy, and side effects of medications
  
  

• Adjust therapy based on labs, symptoms, and guidelines
  
  

7. Health Certificates

• Fitness certificates: for employment, sports, school
  
  

• Medical certificates: for sick leave, chronic conditions, or immunization status
  
  

• Ensure documentation matches clinical assessment
  
  

8. Referral Letters & Medico-Legal Documentation

• Provide structured referral letters with diagnosis, current therapy, and reason for referral
  
  

• Maintain medico-legal records for injury, assault, or occupational health
  
  

9. Emergency Stabilization Before Referral

• Provide first aid, CPR, oxygen, or stabilization as required
  
  

• Document interventions, vital signs, and patient response
  
  

• Ensure safe transport with clear instructions to receiving facility
  
  

Patient Instructions / Ethical Notes:

• Explain procedures and follow-up clearly to patients
  
  

• Maintain confidentiality, document care thoroughly
  
  

• Encourage preventive health and adherence to chronic disease management

II. GENERAL MEDICINE (ADULT)

1. Acute Illnesses / Presentations:

• Sudden onset fever, malaise, or systemic symptoms
  
  

• Rapid assessment to differentiate self-limiting vs potentially serious conditions
  
  

Case 2a – Fever & Viral Infection

Diagnosis:

• Acute viral infection presenting with fever, malaise, myalgia, and mild respiratory or gastrointestinal symptoms
  
  

Patient Presentation / Wordings:

• “I have a fever, body aches, and feel very tired.”
  
  

• “My throat is sore, and I have a runny nose and mild cough.”
  
  

• “I’ve had diarrhea and mild vomiting for a day or two.”
  
  

Examination / Assessment:

• Vital signs: temperature, pulse, BP, respiratory rate, oxygen saturation
  
  

• General assessment: hydration, consciousness, signs of systemic infection
  
  

• ENT: throat, tonsils, nasal mucosa
  
  

• Lung auscultation for crackles, wheezing, or signs of pneumonia
  
  

• Abdominal examination if gastrointestinal symptoms present
  
  

Investigations (if indicated):

• CBC for persistent high fever
  
  

• Rapid antigen tests if influenza or COVID-19 suspected
  
  

• Stool or other labs only if severe or persistent symptoms
  
  

Treatment / Prescription / Management:

A. Supportive Care:

• Hydration: oral fluids, ORS if vomiting/diarrhea present
  
  

• Rest and avoidance of strenuous activity
  
  

B. Symptomatic Relief:

• Antipyretics: Paracetamol 500–1000 mg PO every 6 hours PRN (max 4 g/day)
  
  

• NSAIDs for pain or myalgia: Ibuprofen 400 mg PO every 8 hours with food (if no contraindications)
  
  

• Saline nasal drops or steam inhalation for congestion
  
  

• Throat lozenges for sore throat
  
  

C. Antibiotics:

• Not indicated unless bacterial infection suspected (persistent high fever, purulent discharge, localized signs)
  
  

Expected Side Effects / Precautions:

• Paracetamol: hepatotoxicity if overdosed
  
  

• NSAIDs: GI irritation, renal impairment, caution in hypertensive or renal patients
  
  

Monitoring / Follow-Up:

• Watch for warning signs: persistent high fever >3 days, difficulty breathing, chest pain, altered consciousness
  
  

• Daily self-monitoring of temperature and symptoms
  
  

• Follow-up in clinic if symptoms worsen or persist
  
  

Referral Criteria:

• Respiratory distress, hypoxia, or pneumonia
  
  

• Severe dehydration due to vomiting/diarrhea
  
  

• Signs of sepsis or systemic deterioration
  
  

Patient Instructions:

• Maintain adequate fluid intake and rest
  
  

• Take medications as prescribed, do not exceed recommended doses
  
  

• Monitor for warning signs and seek immediate care if they occur
  
  

• Avoid close contact with others if contagious (cough, sneezing)
  
  

Legal / Ethical Justification:

• Family physicians provide evidence-based symptomatic management for viral illnesses
  
  

• Avoid unnecessary antibiotics to prevent antimicrobial resistance
  
  

• Proper documentation of assessment and counseling ensures medicolegal protection
  
  

Case 2b – Pharyngitis, Tonsillitis & Mild Respiratory Infections

Diagnosis:

• Acute bacterial or viral pharyngitis/tonsillitis or mild lower respiratory tract infection (bronchitis, mild pneumonia)
  
  

Patient Presentation / Wordings:

• “My throat is sore and it hurts to swallow.”
  
  

• “I have fever, headache, and swollen glands in my neck.”
  
  

• “I have a cough with mild fever and fatigue.”
  
  

Examination / Assessment:

• Vital signs: temperature, pulse, BP, respiratory rate
  
  

• Throat and oral cavity: redness, exudates, tonsillar enlargement
  
  

• Cervical lymph nodes: tenderness, enlargement
  
  

• Lung auscultation: check for crackles, wheezing, or consolidation
  
  

• Assess hydration, general condition, and oxygen saturation
  
  

Investigations (if indicated):

• Rapid antigen detection test for Group A Streptococcus
  
  

• Throat swab culture if persistent or severe
  
  

• Chest X-ray if pneumonia suspected
  
  

• CBC if high fever or systemic signs
  
  

Treatment / Prescription / Management:

A. Symptomatic Relief:

• Analgesics / antipyretics: Paracetamol 500–1000 mg PO every 6 hours PRN
  
  

• NSAIDs: Ibuprofen 400 mg PO every 8 hours with food if inflammation present
  
  

• Saltwater gargle, warm fluids, throat lozenges
  
  

B. Antibiotic Therapy (if bacterial infection suspected or confirmed):

• First-line: Amoxicillin 500 mg PO TID × 10 days
  
  

• Penicillin allergy: Azithromycin 500 mg PO day 1, then 250 mg PO daily × 4 days
  
  

C. Supportive Measures:

• Adequate hydration, rest, and avoidance of irritants (smoke, dust)
  
  

• Monitor for worsening symptoms or complications (peritonsillar abscess, pneumonia)
  
  

Expected Side Effects / Precautions:

• Antibiotics: diarrhea, rash, hypersensitivity reactions
  
  

• NSAIDs: GI upset, renal effects
  
  

• Paracetamol: hepatotoxicity if overdosed
  
  

Monitoring / Follow-Up:

• Reassess if symptoms persist beyond 7 days or worsen
  
  

• Watch for respiratory distress, high fever, or signs of systemic infection
  
  

• Ensure completion of full antibiotic course if prescribed
  
  

Referral Criteria:

• Severe pain, trismus, peritonsillar abscess
  
  

• Respiratory distress or hypoxia
  
  

• Persistent high fever, sepsis, or immunocompromised patients
  
  

Patient Instructions:

• Take medications exactly as prescribed
  
  

• Rest and maintain hydration
  
  

• Avoid close contact with others if contagious
  
  

• Return to clinic for worsening symptoms or complications
  
  

Legal / Ethical Justification:

• Family physicians provide primary care for acute pharyngitis and mild respiratory infections
  
  

• Judicious antibiotic use prevents resistance
  
  

• Proper documentation of diagnosis, treatment, and follow-up protects against legal liability
  
  

Case 2c – Gastroenteritis, Dyspepsia & Food Poisoning

Diagnosis:

• Acute gastrointestinal illness due to infection (viral, bacterial, or parasitic) or food-related causes
  
  

• Presenting with diarrhea, vomiting, abdominal pain, or dyspepsia
  
  

Patient Presentation / Wordings:

• “I have diarrhea and vomiting after eating outside food.”
  
  

• “I feel nauseated, bloated, and have stomach cramps.”
  
  

• “I vomited several times and my stomach hurts.”
  
  

Examination / Assessment:

• Vital signs: temperature, pulse, BP, respiratory rate
  
  

• Hydration status: mucous membranes, skin turgor, capillary refill
  
  

• Abdominal examination: tenderness, distension, bowel sounds
  
  

• Signs of systemic infection or sepsis
  
  

Investigations (if indicated):

• Stool microscopy, culture if bloody diarrhea or severe infection suspected
  
  

• CBC if high fever or systemic symptoms
  
  

• Electrolytes if significant dehydration or persistent vomiting
  
  

Treatment / Prescription / Management:

A. Hydration & Supportive Care:

• Oral rehydration solution (ORS) for mild to moderate dehydration
  
  

• IV fluids (Ringer’s lactate or normal saline) if severe dehydration
  
  

• Encourage small, frequent meals once vomiting subsides
  
  

B. Symptomatic Relief:

• Antiemetics: Ondansetron 4 mg PO/ODT every 8 hours PRN
  
  

• Antidiarrheals (if non-bloody and mild): Loperamide 4 mg initial, then 2 mg after each loose stool; max 16 mg/day
  
  

• Antacids or proton pump inhibitors for dyspepsia
  
  

C. Antibiotics (if indicated):

• Only for suspected bacterial infections (severe, bloody diarrhea, high-risk patients)
  
  

• Ciprofloxacin 500 mg PO BID × 5 days (adult, adjust per local guidelines)
  
  

Expected Side Effects / Precautions:

• Antiemetics: mild constipation or headache
  
  

• Antidiarrheals: abdominal cramps, constipation; avoid in bloody diarrhea
  
  

• Antibiotics: diarrhea, rash, hypersensitivity
  
  

Monitoring / Follow-Up:

• Monitor hydration status and symptom improvement
  
  

• Daily follow-up for persistent vomiting or diarrhea
  
  

• Hospital referral if worsening dehydration, systemic infection, or inability to tolerate oral intake
  
  

Referral Criteria:

• Severe dehydration, hypotension, or shock
  
  

• Bloody diarrhea, high-grade fever, or persistent vomiting
  
  

• Signs of sepsis or severe systemic involvement
  
  

Patient Instructions:

• Maintain adequate oral fluids and rest
  
  

• Eat light, bland diet once tolerated
  
  

• Avoid self-medication with unnecessary antibiotics
  
  

• Return to clinic if symptoms worsen or persist beyond 48–72 hours
  
  

Legal / Ethical Justification:

• Family physicians provide timely, evidence-based care for acute gastroenteritis
  
  

• Proper documentation and patient counseling protect against legal claims
  
  

• Judicious use of antibiotics prevents resistance and ensures patient safety
  
  

Case 2d – Migraine, Tension Headache, Vertigo

A. Migraine (Acute / Recurrent)

Diagnosis: Migraine without aura / with aura

Patient Presentation / Wordings:

• “I have a severe throbbing headache, often on one side.”
  
  

• “Light and sound make it worse.”
  
  

• “Sometimes I see flashes or visual disturbances before a headache.”
  
  

• “Nausea or vomiting accompanies the headache.”
  
  

Examination / Red Flags:

• Normal neuro exam in typical cases
  
  

• Red flags for referral: sudden severe headache (“worst ever”), neurological deficits, vision loss, fever, neck stiffness, trauma
  
  

Treatment / Prescription:

• Acute attack:
  
  

  • Paracetamol 500–1000 mg orally every 6–8 hours as needed (max 4 g/day)
    
    

  • NSAID (Ibuprofen 400–600 mg orally every 8 hours as needed) – take with food to reduce GI irritation
    
    

  • Sumatriptan 50–100 mg orally at onset if moderate–severe attack, may repeat after 2 hours if no relief (max 200 mg/day)
    
    

• Preventive therapy (if >4 attacks/month):
  
  

  • Propranolol 20–40 mg orally twice daily
    
    

  • OR Amitriptyline 10–25 mg orally at bedtime
    
    

Expected Side Effects:

• Paracetamol: rare liver toxicity (avoid >4 g/day)
  
  

• Ibuprofen: GI irritation, heartburn, rare kidney effects
  
  

• Sumatriptan: flushing, chest tightness, dizziness
  
  

• Propranolol: fatigue, bradycardia, hypotension
  
  

• Amitriptyline: drowsiness, dry mouth, weight gain
  
  

Monitoring: Symptom diary, headache frequency, BP if on beta-blocker

Referral Criteria: Neurological deficits, sudden severe headache, unresponsive migraine, medication overuse headache

Patient Instructions: Take acute medications at onset, maintain headache diary, avoid triggers, rest in quiet/dark room

Legal/Ethical Justification: Management of typical migraine attacks and preventive therapy is within Family Medicine scope; referral criteria ensure patient safety

B. Tension Headache

Diagnosis: Tension-Type Headache

Patient Presentation / Wordings:

• “I feel a tight band-like pressure around my head.”
  
  

• “Pain is mild to moderate, lasts hours to days.”
  
  

• “No nausea or visual disturbances.”
  
  

Treatment / Prescription:

• Paracetamol 500–1000 mg orally every 6–8 hours as needed
  
  

• NSAID (Ibuprofen 200–400 mg orally every 6–8 hours as needed)
  
  

• Non-pharmacologic: stress management, physiotherapy, sleep hygiene
  
  

Expected Side Effects: Same as above for paracetamol and NSAIDs

Monitoring: Frequency, severity, impact on daily life

Referral Criteria: Change in headache pattern, neurological signs, refractory headaches

Patient Instructions: Take medication as needed, maintain stress management, ergonomic adjustments, adequate sleep

Legal/Ethical Justification: Symptomatic management of tension headaches is within Family Medicine scope; red flags warrant referral

C. Vertigo (Peripheral / Benign Positional Vertigo)

Diagnosis: Benign Paroxysmal Positional Vertigo (BPPV) / Vestibular Vertigo

Patient Presentation / Wordings:

• “I feel like the room is spinning when I move my head.”
  
  

• “Symptoms last seconds to minutes, triggered by head movement.”
  
  

• “Sometimes nausea accompanies it.”
  
  

Examination / Red Flags:

• Dix-Hallpike maneuver positive for BPPV
  
  

• Normal neurological exam if peripheral
  
  

• Red flags: new neurological deficit, sudden hearing loss, severe headache → urgent referral
  
  

Treatment / Prescription:

• Epley maneuver / vestibular repositioning exercises (first-line)
  
  

• Meclizine 25 mg orally 1–2 times daily for short-term symptom relief if severe
  
  

• Anti-emetics (Ondansetron 4 mg orally every 8 hours) if persistent nausea
  
  

Expected Side Effects:

• Meclizine: drowsiness, dry mouth
  
  

• Ondansetron: headache, constipation
  
  

Monitoring: Symptom resolution, recurrence, ability to perform daily activities

Referral Criteria: Persistent vertigo >2 weeks, neurological deficits, hearing loss, unsteady gait, suspected central cause

Patient Instructions: Perform repositioning exercises as instructed, avoid sudden head movements, take medications if needed for nausea/dizziness

Legal/Ethical Justification: Diagnosis and initial management of BPPV and vestibular vertigo are within Family Medicine scope; referral criteria defined for central or complicated vertigo

Case 2e – Urinary Tract Infection, Cystitis & Prostatitis (Initial Management)

Diagnosis:

• Acute uncomplicated urinary tract infection (UTI)
  
  

• Cystitis in adults
  
  

• Suspected bacterial prostatitis (initial management)
  
  

Patient Presentation / Wordings:

• “I have a burning sensation when urinating.”
  
  

• “I feel the urge to urinate frequently, but only pass small amounts.”
  
  

• “I have lower abdominal discomfort or mild fever.”
  
  

• “I have lower back or perineal pain with urinary symptoms (possible prostatitis).”
  
  

Examination / Assessment:

• Vital signs: temperature, pulse, BP
  
  

• Abdominal exam: suprapubic tenderness
  
  

• Flank pain: costovertebral angle tenderness
  
  

• Genitourinary exam: prostate palpation in suspected prostatitis
  
  

• Assess hydration, systemic involvement, and comorbidities
  
  

Investigations (if indicated):

• Urine dipstick: leukocytes, nitrites, hematuria
  
  

• Urine microscopy / culture and sensitivity if recurrent or complicated
  
  

• CBC if systemic infection suspected
  
  

• PSA and renal function if prostatitis suspected
  
  

Treatment / Prescription / Management:

A. Uncomplicated UTI / Cystitis:

• First-line: Nitrofurantoin 100 mg PO BID × 5 days
  
  

• Alternative: Trimethoprim-sulfamethoxazole 160/800 mg PO BID × 3 days (if no resistance risk)
  
  

• Symptomatic relief: Paracetamol 500–1000 mg PO q6h PRN for dysuria
  
  

B. Suspected Acute Bacterial Prostatitis:

• Empiric oral antibiotics: Ciprofloxacin 500 mg PO BID × 10–14 days
  
  

• Pain management: NSAIDs (Ibuprofen 400 mg PO q8h with food)
  
  

• Supportive measures: hydration, warm sitz baths
  
  

Expected Side Effects / Precautions:

• Nitrofurantoin: GI upset, pulmonary reactions (rare)
  
  

• Ciprofloxacin: GI upset, tendonitis risk, photosensitivity
  
  

• NSAIDs: GI irritation, renal caution
  
  

Monitoring / Follow-Up:

• Symptom improvement within 48–72 hours
  
  

• Reassess if persistent fever, worsening pain, or urinary obstruction
  
  

• Urine culture follow-up in recurrent or complicated cases
  
  

Referral Criteria:

• Severe infection with high fever, systemic symptoms, or sepsis
  
  

• Recurrent UTIs or resistant organisms
  
  

• Suspected complicated prostatitis, obstruction, or abscess
  
  

Patient Instructions:

• Complete full antibiotic course
  
  

• Drink adequate fluids
  
  

• Avoid irritants (caffeine, alcohol) during treatment
  
  

• Return to clinic if symptoms persist or worsen
  
  

Legal / Ethical Justification:

• Family physicians provide initial evaluation and management of UTIs and prostatitis
  
  

• Proper documentation and patient counseling ensure medicolegal protection
  
  

• Timely treatment reduces risk of complications, hospitalization, and antibiotic resistance
  
  

Case 2f – Allergic Reactions, Urticaria & Anaphylaxis

Diagnosis:

• Acute allergic reaction ranging from mild urticaria to life-threatening anaphylaxis
  
  

Patient Presentation / Wordings:

• “I have red, itchy hives all over my body.”
  
  

• “My lips and face are swelling, and I feel short of breath.”
  
  

• “I have a sudden rash with difficulty breathing after eating or taking medication.”
  
  

Examination / Assessment:

• Vital signs: BP, pulse, respiratory rate, oxygen saturation
  
  

• Airway assessment: check for stridor, hoarseness, or swelling of tongue/throat
  
  

• Skin: urticaria, angioedema, redness
  
  

• Respiratory: wheezing, accessory muscle use
  
  

• Cardiovascular: hypotension, tachycardia
  
  

• Assess severity: mild, moderate, severe (anaphylaxis)
  
  

Investigations (if indicated):

• Usually clinical diagnosis; labs only if systemic involvement or for follow-up
  
  

• Consider CBC, serum tryptase (post-anaphylaxis)
  
  

Treatment / Prescription / Management:

A. Mild Allergic Reaction / Urticaria:

• Antihistamines: Cetirizine 10 mg PO OD or Loratadine 10 mg PO OD
  
  

• Symptomatic care: topical calamine, avoid triggers
  
  

B. Moderate to Severe / Anaphylaxis:

• Immediate: Epinephrine 0.3–0.5 mg IM (adult) into mid-outer thigh; may repeat every 5–15 min if needed
  
  

• Oxygen therapy 5–10 L/min via face mask
  
  

• IV fluids: 0.9% normal saline, 1–2 L rapidly for hypotension
  
  

• Adjunct: corticosteroids (Hydrocortisone 100–200 mg IV) and antihistamines (Diphenhydramine 25–50 mg IV/IM)
  
  

• Monitor airway, BP, and pulse continuously
  
  

C. Referral / Escalation:

• All cases of anaphylaxis require immediate transfer to emergency care
  
  

• Patients with respiratory distress, hypotension, or systemic involvement
  
  

Expected Side Effects / Precautions:

• Epinephrine: transient palpitations, anxiety, tremor
  
  

• Antihistamines: drowsiness, dry mouth
  
  

• Corticosteroids: hyperglycemia, fluid retention
  
  

Monitoring / Follow-Up:

• Observe patient for biphasic reactions for at least 4–6 hours after severe reactions
  
  

• Educate patient on avoidance of triggers and emergency epinephrine use
  
  

• Prescribe epinephrine auto-injector if recurrent anaphylaxis risk
  
  

Patient Instructions:

• Avoid known allergens
  
  

• Carry epinephrine auto-injector if indicated
  
  

• Seek immediate medical care for future severe reactions
  
  

• Take antihistamines as prescribed for mild reactions
  
  

Legal / Ethical Justification:

• Family physicians must stabilize allergic reactions promptly
  
  

• Timely management and proper documentation protect patient safety and physician liability
  
  

• Educating patients on triggers and emergency measures ensures ethical, patient-centered care
  
  

Case 2g – Poisoning or Drug Overdose (First Aid & Referral)

Diagnosis:

• Acute poisoning or drug overdose from accidental or intentional ingestion
  
  

Common Patient Presentations / Wordings

• “I accidentally took too many pills.”
  
  

• “I feel dizzy, nauseous, and weak.”
  
  

• “I have stomach pain and vomiting.”
  
  

• “I feel short of breath or my heart is racing.”
  
  

• “I don’t know exactly what substance I ingested.”
  
  

• “I took something intentionally to harm myself.”
  
  

• “My skin feels clammy or I am sweating a lot.”
  
  

• “I feel confused or drowsy.
  
  

Objective Findings / Red Flags

• Vitals: Hypotension, tachycardia, bradycardia, hypoxia
  
  

• General Exam: Altered consciousness, drowsiness, agitation, cyanosis
  
  

• Red Flags (refer immediately / emergency):
  
  

  • Respiratory distress
    
    

  • Seizures
    
    

  • Coma or severe altered mental status
    
    

  • Hypotension or shock
    
    

  • Cardiac arrhythmias
    
    

  • Ingestion of life-threatening substances (e.g., organophosphates, opioids, paracetamol in toxic dose, cyanide)
    
    

Initial Diagnostic Approach in Clinic

• History: Substance ingested, dose, time of ingestion, co-ingestants, comorbidities
  
  

• Examination: Vitals, airway, breathing, circulation, neurological status
  
  

• Basic Tests (if available and safe):
  
  

  • Blood glucose (rule out hypoglycemia)
    
    

  • ECG if cardiotoxic drug suspected
    
    

  • Serum electrolytes, renal, liver function if ingestion >24 hrs or suspected toxic drug
    
    

  • Blood paracetamol / salicylate level if suspected overdose
    
    

5. Management / Treatment in Primary Care (Prescription-Ready / First Aid)

A. Immediate Stabilization

• Airway, Breathing, Circulation (ABC): Ensure airway is patent, oxygen if needed
  
  

• IV access if hypotensive, for fluids: Normal Saline 500–1000 ml bolus if hypotensive
  
  

• Activated Charcoal: 50 g orally or via NG tube if within 1–2 hours of ingestion (except corrosives, hydrocarbons)
  
  

B. Symptomatic / Specific Antidotes (if available)

• Paracetamol overdose: N-acetylcysteine (NAC) protocol
  
  

• Opioid overdose: Naloxone 0.4–2 mg IV/IM/SC repeat as needed
  
  

• Benzodiazepine overdose: Usually supportive; flumazenil only if severe and no chronic use
  
  

• Others: Treat as per standard toxicology protocols
  
  

C. Monitoring Instructions

• Continuous monitoring of vitals, oxygen saturation, mental status
  
  

• Record fluid balance and urine output
  
  

• Monitor for arrhythmias or seizures
  
  

6. Referral Criteria / When to Escalate

• All suspected poisoning or overdose cases require immediate hospital referral
  
  

• Any hemodynamic instability, respiratory compromise, altered consciousness, or seizures → emergency care
  
  

• Corrosive ingestion, multi-drug overdose, or unknown substance → hospital referral
  
  

• Long-term monitoring for chronic toxicity or psychiatric evaluation if intentional ingestion

Expected Side Effects / Precautions:

• Activated charcoal: constipation, black stools, vomiting
  
  

• IV fluids: monitor for overload in patients with renal/cardiac disease
  
  

• Antidotes: follow dosing strictly to avoid toxicity
  
  

Monitoring / Follow-Up:

• Serial vital signs and neurological assessment
  
  

• Laboratory monitoring: electrolytes, renal/liver function
  
  

• Psychological evaluation if intentional overdose
  
  

Patient Instructions:

• Avoid repeat exposure to toxic substances
  
  

• Take medications only as prescribed
  
  

• Follow-up for any delayed effects or complications
  
  

• Seek immediate care if symptoms worsen
  
  

Legal / Ethical Justification:

• Family physicians must provide prompt first aid for poisoning and initiate referral
  
  

• Accurate documentation is essential for patient safety and medicolegal protection
  
  

• Early intervention reduces morbidity, mortality, and long-term complications
  
  

2. Chronic Conditions

Case 2h – Hypertension (Chronic Management)

Diagnosis:

• Primary (essential) hypertension
  
  

• Secondary hypertension if underlying cause suspected
  
  

Patient Presentation / Wordings:

• “My blood pressure readings are high at home.”
  
  

• “I feel dizzy and have occasional headaches.”
  
  

• “I am being followed up for high blood pressure.”
  
  

Examination / Assessment:

• Vital signs: multiple BP readings in both arms, pulse, weight, BMI
  
  

• Cardiovascular exam: heart sounds, murmurs, peripheral pulses
  
  

• Fundoscopy: hypertensive retinopathy
  
  

• Check for signs of target organ damage: ECG, renal function, echocardiography if indicated
  
  

Investigations:

• Routine: CBC, electrolytes, renal function, fasting glucose, lipid profile
  
  

• ECG for left ventricular hypertrophy or ischemic changes
  
  

• Urinalysis for proteinuria
  
  

• Optional: echocardiography if cardiovascular disease suspected
  
  

Treatment / Prescription / Management:

A. Lifestyle Modifications:

• Reduce salt intake (<5 g/day), DASH diet
  
  

• Weight management and regular physical activity
  
  

• Limit alcohol, avoid smoking
  
  

• Stress management techniques
  
  

B. Pharmacological Therapy (Individualized):

• First-line:
  
  

  • ACE inhibitors (e.g., Lisinopril 10–20 mg PO OD)
    
    

  • ARBs (e.g., Losartan 50–100 mg PO OD)
    
    

  • Calcium channel blockers (e.g., Amlodipine 5–10 mg PO OD)
    
    

  • Thiazide diuretics (e.g., Hydrochlorothiazide 12.5–25 mg PO OD)
    
    

• Combination therapy if BP not controlled with monotherapy
  
  

• Monitoring: adjust doses based on BP response and tolerability
  
  

C. Expected Side Effects / Precautions:

• ACE inhibitors: dry cough, hyperkalemia, angioedema
  
  

• ARBs: hyperkalemia, dizziness
  
  

• CCBs: peripheral edema, flushing
  
  

• Diuretics: hypokalemia, dehydration, electrolyte imbalance
  
  

Monitoring / Follow-Up:

• Home BP monitoring: 1–2 times daily, record readings
  
  

• Clinic BP every 4–6 weeks initially until controlled, then every 3–6 months
  
  

• Monitor renal function and electrolytes if on ACE inhibitors, ARBs, or diuretics
  
  

• Screen for target organ damage periodically
  
  

Referral Criteria:

• Resistant hypertension (BP not controlled on ≥3 medications)
  
  

• Secondary hypertension suspected (renal artery stenosis, endocrine disorders)
  
  

• Target organ damage or complications (heart failure, CKD, stroke)
  
  

Patient Instructions:

• Take medications at the same time every day
  
  

• Maintain lifestyle modifications strictly
  
  

• Monitor BP at home and keep a log
  
  

• Report symptoms: dizziness, fainting, swelling, persistent cough
  
  

• Do not stop medications abruptly
  
  

Legal / Ethical Justification:

• Family physicians manage chronic hypertension to reduce cardiovascular risk
  
  

• Documenting BP readings, treatment decisions, and counseling protects against legal claims
  
  

• Following evidence-based guidelines ensures ethical, safe care
  
  

Case 2i – Diabetes Mellitus (Chronic Management)

Diagnosis:

• Type 2 Diabetes Mellitus (T2DM)
  
  

• Poorly controlled or newly diagnosed adult diabetes
  
  

Patient Presentation / Wordings:

• “I feel very thirsty and urinate frequently.”
  
  

• “My sugar readings are high at home.”
  
  

• “I am here for routine diabetes follow-up.”
  
  

Examination / Assessment:

• Vital signs: BP, pulse, BMI, waist circumference
  
  

• General assessment: signs of dehydration, infection
  
  

• Foot examination: ulcers, neuropathy
  
  

• Ophthalmic: refer for retinopathy screening
  
  

• Neurological: peripheral neuropathy signs (vibration, monofilament test)
  
  

Investigations:

• Fasting blood glucose, postprandial glucose
  
  

• HbA1c every 3–6 months
  
  

• Lipid profile, renal function tests (creatinine, eGFR), urinalysis for microalbuminuria
  
  

• ECG if cardiovascular risk present
  
  

Treatment / Prescription / Management:

A. Lifestyle Modifications:

• Balanced diet with carbohydrate control
  
  

• Weight management and regular exercise
  
  

• Smoking cessation, limit alcohol
  
  

• Educate on hypoglycemia recognition and management
  
  

B. Pharmacological Therapy:

• First-line: Metformin 500–1000 mg PO BID (titrate to tolerance)
  
  

• Second-line / add-on therapy:
  
  

  • Sulfonylureas (e.g., Glimepiride 1–4 mg PO OD)
    
    

  • DPP-4 inhibitors, SGLT2 inhibitors, or GLP-1 agonists per guidelines and patient comorbidities
    
    

• Insulin therapy if inadequate control on oral agents or in acute complications
  
  

C. Expected Side Effects / Precautions:

• Metformin: GI upset, lactic acidosis (rare, avoid in CKD stage ≥3)
  
  

• Sulfonylureas: hypoglycemia
  
  

• SGLT2 inhibitors: urinary infections, dehydration
  
  

• Insulin: hypoglycemia, weight gain
  
  

Monitoring / Follow-Up:

• Self-monitoring of blood glucose (SMBG) as instructed
  
  

• HbA1c every 3–6 months
  
  

• Annual screening for retinopathy, nephropathy, neuropathy, cardiovascular disease
  
  

• Monitor for complications: foot care, infection prevention
  
  

Referral Criteria:

• Poorly controlled diabetes despite optimal therapy
  
  

• Complications: diabetic foot, retinopathy, nephropathy, neuropathy
  
  

• Pregnancy, planned surgery, or acute metabolic complications
  
  

Patient Instructions:

• Take medications as prescribed and do not skip doses
  
  

• Follow dietary and exercise plan strictly
  
  

• Monitor blood sugar at home and record readings
  
  

• Report symptoms: hypoglycemia, infections, vision changes, foot ulcers
  
  

Legal / Ethical Justification:

• Family physicians provide comprehensive chronic diabetes care
  
  

• Documentation of glycemic control, counseling, and complications protects against medicolegal issues
  
  

• Evidence-based management reduces morbidity, hospitalization, and long-term complications
  
  

Case 2j – Dyslipidemia (Chronic Management)

Diagnosis:

• Primary or secondary dyslipidemia
  
  

• Elevated cholesterol, LDL, triglycerides, or low HDL
  
  

Patient Presentation / Wordings:

• “My cholesterol is high on lab tests.”
  
  

• “I have a family history of heart disease.”
  
  

• “I am here for routine lipid management.”
  
  

Examination / Assessment:

• Vital signs: BP, heart rate
  
  

• BMI, waist circumference, signs of metabolic syndrome
  
  

• Cardiovascular exam: heart sounds, peripheral pulses
  
  

• Assess for xanthomas, corneal arcus
  
  

• Labs: fasting lipid profile, fasting glucose, renal and liver function tests
  
  

Investigations:

• Baseline: Total cholesterol, LDL, HDL, triglycerides
  
  

• Cardiac risk assessment: Framingham score or ASCVD risk
  
  

• Repeat lipid profile every 3–12 months depending on therapy
  
  

Treatment / Prescription / Management:

A. Lifestyle Modifications:

• Diet: reduce saturated fat, trans fat, cholesterol; increase fiber
  
  

• Weight management and regular aerobic exercise
  
  

• Smoking cessation and limit alcohol
  
  

• Educate patient about cardiovascular risk reduction
  
  

B. Pharmacological Therapy:

• First-line: Statins (e.g., Atorvastatin 10–40 mg PO OD; dose titrated per LDL target)
  
  

• Alternatives / add-ons: Ezetimibe, fibrates, or PCSK9 inhibitors for refractory cases
  
  

• Monitor adherence and tolerance
  
  

C. Expected Side Effects / Precautions:

• Statins: myalgia, mild liver enzyme elevation, rarely rhabdomyolysis
  
  

• Fibrates: GI upset, gallstones, myopathy (especially with statins)
  
  

• Monitor liver function tests before starting and periodically
  
  

Monitoring / Follow-Up:

• Lipid profile 6–12 weeks after initiating or adjusting therapy
  
  

• Monitor for side effects (muscle pain, liver enzymes)
  
  

• Cardiovascular risk reassessment annually
  
  

• Reinforce lifestyle modifications at every visit
  
  

Referral Criteria:

• Severe or refractory dyslipidemia
  
  

• Familial hypercholesterolemia
  
  

• Patients with premature or multiple cardiovascular events despite therapy
  
  

Patient Instructions:

• Take statins at the same time daily, preferably at night
  
  

• Maintain healthy diet and regular exercise
  
  

• Report muscle pain, dark urine, or persistent fatigue
  
  

• Keep scheduled follow-up visits and labs
  
  

Legal / Ethical Justification:

• Family physicians provide primary care for dyslipidemia to prevent cardiovascular events
  
  

• Documentation of therapy, counseling, and monitoring ensures medicolegal safety
  
  

• Evidence-based treatment aligns with ethical standards for chronic disease management
  
  

Case 2k – Thyroid Disorders (Chronic Management)

Diagnosis:

• Hypothyroidism (primary or secondary)
  
  

• Hyperthyroidism (Graves’ disease, toxic nodular goiter, or other causes)
  
  

Patient Presentation / Wordings:

• Hypothyroidism: “I feel tired, gain weight, and feel cold all the time.”
  
  

• Hyperthyroidism: “I feel anxious, my heart races, and I have lost weight.”
  
  

• “I am here for routine thyroid follow-up or lab review.”
  
  

Examination / Assessment:

• Vital signs: BP, pulse (tachycardia in hyperthyroidism)
  
  

• General: BMI, weight changes, signs of anemia or edema
  
  

• Thyroid: palpation for size, nodules, tenderness, asymmetry
  
  

• Eyes: exophthalmos in Graves’ disease
  
  

• Reflexes: delayed in hypothyroidism, brisk in hyperthyroidism
  
  

• Skin: dry and coarse (hypothyroid), warm and moist (hyperthyroid)
  
  

Investigations:

• TSH, free T4, free T3
  
  

• Anti-TPO antibodies if autoimmune thyroid disease suspected
  
  

• ECG if arrhythmia or tachycardia present
  
  

• Ultrasound if nodules detected
  
  

Treatment / Prescription / Management:

A. Hypothyroidism:

• Levothyroxine 50–150 µg PO daily (start low and titrate based on TSH)
  
  

• Take on empty stomach, 30–60 minutes before breakfast
  
  

• Monitor TSH every 6–8 weeks initially, then every 6–12 months once stable
  
  

B. Hyperthyroidism (Initial Management / Chronic Care):

• Beta-blockers (e.g., Propranolol 10–40 mg PO TID) for symptom control
  
  

• Antithyroid drugs (e.g., Methimazole 5–20 mg PO daily)
  
  

• Monitor TSH, free T4, free T3 every 4–6 weeks initially
  
  

• Referral to endocrinology for definitive therapy (radioiodine or surgery) if indicated
  
  

Expected Side Effects / Precautions:

• Levothyroxine: palpitations, insomnia if overdosed
  
  

• Methimazole: rash, agranulocytosis (monitor CBC), hepatotoxicity
  
  

• Beta-blockers: bradycardia, fatigue, hypotension
  
  

Monitoring / Follow-Up:

• TSH, free T4 every 6–12 weeks until euthyroid
  
  

• Symptom review: energy, weight, palpitations, tremors
  
  

• ECG if arrhythmias or prolonged tachycardia present
  
  

• Adjust doses based on labs and clinical response
  
  

Referral Criteria:

• Large goiter causing compressive symptoms
  
  

• Nodules suspicious for malignancy
  
  

• Poorly controlled hyperthyroidism or severe hypothyroidism
  
  

• Pregnancy or planning conception
  
  

Patient Instructions:

• Take medications consistently and at the same time each day
  
  

• Monitor for symptoms of hypo- or hyperthyroidism
  
  

• Attend all follow-up lab tests
  
  

• Avoid sudden discontinuation of therapy
  
  

• Educate on recognizing agranulocytosis (fever, sore throat) with antithyroid drugs
  
  

Legal / Ethical Justification:

• Family physicians manage chronic thyroid disorders to prevent complications (cardiac, metabolic, growth issues)
  
  

• Proper documentation and patient education ensure medicolegal protection
  
  

• Evidence-based therapy ensures safe, ethical chronic care
  
  

Case 2l – Asthma & COPD (Chronic Management)

Diagnosis:

• Chronic asthma (mild, moderate, or severe persistent)
  
  

• Chronic obstructive pulmonary disease (COPD) – GOLD stages 1–3
  
  

Patient Presentation / Wordings:

• “I have a cough, wheezing, and shortness of breath, especially at night.” (Asthma)
  
  

• “I get short of breath on exertion and have a chronic cough with sputum.” (COPD)
  
  

• “I want advice on managing my inhalers and flare-ups.”
  
  

Examination / Assessment:

• Vital signs: BP, pulse, respiratory rate, oxygen saturation
  
  

• Lung auscultation: wheezes, crackles, reduced breath sounds
  
  

• Assess inhaler technique
  
  

• General assessment: BMI, signs of right heart strain in advanced COPD
  
  

• Peak expiratory flow rate (PEFR) in asthma
  
  

Investigations:

• Spirometry: FEV1, FVC, FEV1/FVC ratio
  
  

• Chest X-ray if suspicion of infection, COPD complications, or comorbidities
  
  

• Pulse oximetry at rest and exertion
  
  

Treatment / Prescription / Management:

A. Asthma (Chronic Management):

• Controller medication: Inhaled corticosteroids (ICS) ± long-acting beta-agonists (LABA)
  
  

  • Example: Budesonide 200–400 µg BID
    
    

• Reliever: Short-acting beta-agonist (SABA) PRN
  
  

  • Example: Salbutamol 100–200 µg 2 puffs PRN
    
    

• Adjuncts: Leukotriene receptor antagonists (Montelukast 10 mg PO OD) for allergic asthma
  
  

B. COPD (Stable Management):

• Tiotropium 18 µg via inhaler once daily
  
  

• Salbutamol 100 µg inhaler 1–2 puffs as needed
  
  

• Influenza and pneumococcal vaccination advice
  
  

C. COPD – Mild Exacerbation

• Short course oral corticosteroids: Prednisolone 30–40 mg once daily for 5 days
  
  

• Increase SABA inhaler use
  
  

• Antibiotics only if purulent sputum or infection suspected: Amoxicillin 500 mg orally three times daily for 5–7 days

Expected Side Effects / Precautions:

• ICS: oral thrush, dysphonia; rinse mouth after use
  
  

• Beta-agonists: palpitations, tremor
  
  

• Systemic corticosteroids: hyperglycemia, fluid retention, mood changes
  
  

Monitoring / Follow-Up:

• PEFR monitoring for asthma
  
  

• Symptom diary, exacerbation frequency
  
  

• Annual spirometry for COPD progression
  
  

• Oxygen saturation and exercise tolerance
  
  

• Adherence and correct inhaler technique
  
  

Referral Criteria:

• Frequent exacerbations despite optimal therapy
  
  

• Severe airflow limitation (FEV1 <50% predicted)
  
  

• Respiratory failure or persistent hypoxia
  
  

• Consider pulmonology referral for advanced COPD or difficult-to-control asthma
  
  

Patient Instructions:

• Use inhalers correctly, follow stepwise asthma/COPD action plan
  
  

• Avoid triggers: allergens, smoke, pollution
  
  

• Adhere to vaccination schedule
  
  

• Seek urgent care for severe breathlessness, cyanosis, or wheezing unrelieved by inhalers
  
  

Legal / Ethical Justification:

• Family physicians provide long-term management of chronic respiratory diseases to prevent morbidity and hospitalization
  
  

• Documentation of exacerbations, treatment adjustments, and patient education protects medicolegal safety
  
  

• Evidence-based care aligns with ethical standards for chronic disease management
  
  

Case 2m – Chronic Kidney Disease (CKD, Stages 1–3, Chronic Management)

Diagnosis:

• CKD stage 1–3 (eGFR 30–90 mL/min/1.73 m²)
  
  

• Early CKD due to diabetes, hypertension, or other chronic conditions
  
  

Patient Presentation / Wordings:

• “My kidney tests show mildly reduced function.”
  
  

• “I have swelling in my legs and feel tired.”
  
  

• “I am following up for chronic kidney disease.”
  
  

Examination / Assessment:

• Vital signs: BP, pulse, BMI
  
  

• General: edema, pallor
  
  

• Cardiovascular: heart sounds, peripheral pulses
  
  

• Abdominal: kidney palpation (if palpable), bladder
  
  

• Labs: serum creatinine, eGFR, electrolytes, urinalysis, albumin/creatinine ratio
  
  

• Screen for anemia, mineral bone disease, and proteinuria
  
  

Investigations:

• Baseline: CBC, serum creatinine, eGFR, electrolytes
  
  

• Urinalysis: proteinuria, hematuria
  
  

• Blood pressure monitoring
  
  

• Optional: renal ultrasound if structural abnormalities suspected
  
  

Treatment / Prescription / Management:

A. Blood Pressure Control:

• Target: <130/80 mmHg (if tolerated)
  
  

• ACE inhibitors or ARBs preferred for proteinuria
  
  

  • Example: Lisinopril 10–20 mg PO OD, titrate to effect
    
    

B. Glycemic Control (if diabetic):

• Target HbA1c 7% (individualized)
  
  

• Prefer Metformin if eGFR ≥45; reduce dose or stop if eGFR <30
  
  

C. Lifestyle & Supportive Measures:

• Low-salt diet, moderate protein intake if indicated
  
  

• Maintain hydration, avoid nephrotoxic drugs (NSAIDs, contrast without precautions)
  
  

• Smoking cessation, weight management, exercise
  
  

D. Management of Complications:

• Anemia: Iron supplementation ± erythropoiesis-stimulating agents if Hb <10 g/dL
  
  

• Electrolyte imbalance: monitor K+, adjust diet/medications
  
  

• Bone-mineral disorders: calcium/vitamin D supplementation if needed
  
  

Expected Side Effects / Precautions:

• ACE inhibitors: hyperkalemia, cough, angioedema
  
  

• Metformin: lactic acidosis (rare, avoid in eGFR <30)
  
  

• Monitor electrolytes and kidney function regularly
  
  

Monitoring / Follow-Up:

• Serum creatinine, eGFR, electrolytes every 3–6 months
  
  

• Urinalysis for proteinuria every 6–12 months
  
  

• Blood pressure at every visit
  
  

• Monitor for progression to CKD stage 4–5
  
  

Referral Criteria:

• Rapidly declining renal function or eGFR <30
  
  

• Persistent hyperkalemia or uncontrolled hypertension
  
  

• Severe proteinuria or structural kidney abnormalities
  
  

• Consider nephrology referral for advanced management
  
  

Patient Instructions:

• Take medications as prescribed
  
  

• Avoid over-the-counter NSAIDs or nephrotoxic agents
  
  

• Maintain a kidney-friendly diet and monitor fluid intake if advised
  
  

• Report swelling, fatigue, or sudden changes in urine output
  
  

Legal / Ethical Justification:

• Family physicians manage early CKD to prevent progression and cardiovascular complications
  
  

• Proper documentation of labs, medications, and counseling ensures medicolegal protection
  
  

• Patient-centered, evidence-based care reduces morbidity and preserves kidney function
  
  

Case 2n – Benign Prostatic Hyperplasia (Chronic Management)

Diagnosis:

• Benign prostatic hyperplasia causing lower urinary tract symptoms (LUTS)
  
  

Patient Presentation / Wordings:

• “I have difficulty starting to urinate.”
  
  

• “I wake up at night multiple times to urinate.”
  
  

• “I feel my bladder is not emptying completely.”
  
  

Examination / Assessment:

• Vital signs: BP, pulse
  
  

• Abdominal exam: bladder distension
  
  

• Digital rectal exam (DRE): assess prostate size, nodularity, tenderness
  
  

• Assess urinary flow, post-void residual volume if available
  
  

• Evaluate for hematuria or signs of infection
  
  

Investigations:

• Urinalysis: rule out infection
  
  

• Serum creatinine if concern for obstructive uropathy
  
  

• PSA only if indicated by guidelines (age, risk factors)
  
  

• Optional: Ultrasound for post-void residual and prostate size
  
  

Treatment / Prescription / Management:

A. Medical Therapy:

• Alpha-blockers:
  
  

  • Tamsulosin 0.4 mg PO OD (helps relax prostate smooth muscle, improves urine flow)
    
    

• 5-alpha-reductase inhibitors (if prostate significantly enlarged):
  
  

  • Finasteride 5 mg PO OD (reduces prostate size over months)
    
    

• Monitor for side effects: dizziness, hypotension, sexual dysfunction
  
  

B. Lifestyle & Supportive Measures:

• Reduce evening fluid intake
  
  

• Avoid bladder irritants: caffeine, alcohol
  
  

• Timed voiding, double voiding techniques
  
  

• Monitor symptoms using IPSS (International Prostate Symptom Score)
  
  

Expected Side Effects / Precautions:

• Alpha-blockers: dizziness, postural hypotension, headache
  
  

• 5-alpha-reductase inhibitors: decreased libido, erectile dysfunction, breast tenderness
  
  

• Monitor blood pressure and symptoms periodically
  
  

Monitoring / Follow-Up:

• Symptom reassessment every 3–6 months
  
  

• Repeat PSA if indicated
  
  

• Monitor renal function if obstruction suspected
  
  

• Adjust therapy based on symptom severity and tolerance
  
  

Referral Criteria:

• Acute urinary retention
  
  

• Hematuria, recurrent infections, or suspected malignancy
  
  

• Poor response to medical therapy
  
  

• Large residual volume or upper urinary tract obstruction
  
  

Patient Instructions:

• Take medications consistently, preferably at same time daily
  
  

• Avoid sudden position changes to prevent dizziness
  
  

• Monitor urinary symptoms and report worsening or acute retention
  
  

• Maintain scheduled follow-up appointments
  
  

Legal / Ethical Justification:

• Family physicians manage BPH to improve quality of life and prevent complications
  
  

• Proper documentation and monitoring protect against medicolegal claims
  
  

• Evidence-based, patient-centered therapy ensures safe chronic care
  
  

Case 2o – Arthritis, Gout & Chronic Pain Management

Diagnosis:

• Osteoarthritis, rheumatoid arthritis, or other chronic arthropathies
  
  

• Gout (acute flares and chronic hyperuricemia)
  
  

• Chronic musculoskeletal pain
  
  

Patient Presentation / Wordings:

• “My knees hurt and are stiff in the morning.” (Osteoarthritis/Rheumatoid)
  
  

• “I have sudden severe pain in my big toe, with redness and swelling.” (Gout)
  
  

• “I have persistent joint or back pain affecting my daily activities.” (Chronic pain)
  
  

Examination / Assessment:

• Joint inspection: swelling, redness, deformity, nodules
  
  

• Range of motion, tenderness, warmth
  
  

• Assess for systemic signs: fever, fatigue, weight loss
  
  

• Gout: check for tophi, joint effusion
  
  

• Functional assessment: mobility, activities of daily living
  
  

Investigations:

• CBC, ESR/CRP for inflammatory arthritis
  
  

• Serum uric acid for gout
  
  

• X-rays: joint space narrowing, osteophytes, erosions
  
  

• Optional: joint aspiration for crystals in acute gout or suspected infection
  
  

Treatment / Prescription

A. Osteoarthritis / Chronic Musculoskeletal Pain

• Paracetamol 500–1000 mg orally every 6–8 hours as needed (max 4 g/day)
  
  

• NSAID (Ibuprofen 400 mg orally every 8 hours) as needed for pain (use lowest effective dose, monitor renal/GI status)
  
  

• Topical NSAID gel (Diclofenac 1–2%) 3–4 times daily
  
  

• Physical therapy, weight management, joint protection
  
  

B. Rheumatoid Arthritis (Mild to Moderate, Primary Care Initiation / Referral)

• NSAID (Ibuprofen 400 mg orally every 8 hours) for pain
  
  

• Consider referral to Rheumatology for DMARD initiation (Methotrexate, Hydroxychloroquine)
  
  

• Symptom control and monitoring until specialist care
  
  

C. Gout (Acute Attack)

• NSAID (Indomethacin 50 mg orally three times daily) for 5–7 days
  
  

• Colchicine 0.5–1 mg orally initially, then 0.5 mg every 12 hours until attack resolves
  
  

• Hydration: 2–3 liters/day
  
  

• Avoid purine-rich foods, alcohol
  
  

D. Chronic Gout / Prophylaxis

• Allopurinol 100 mg orally once daily (titrate to target uric acid <6 mg/dL)
  
  

• Lifestyle measures: weight control, hydration, dietary modifications
  
  

Expected Side Effects / Precautions:

• NSAIDs: GI upset, renal impairment, hypertension
  
  

• Colchicine: diarrhea, GI intolerance
  
  

• Allopurinol: rash, hypersensitivity (rare), monitor renal function
  
  

Monitoring / Follow-Up:

• Pain and functional status regularly
  
  

• CBC, renal, and liver function if on long-term NSAIDs or allopurinol
  
  

• Serum uric acid levels periodically in gout
  
  

• Adjust therapy based on symptoms and tolerability
  
  

Referral Criteria:

• Refractory pain or severe functional limitation
  
  

• Joint deformity, significant swelling, or suspected autoimmune arthritis
  
  

• Frequent gout flares despite therapy
  
  

• Consider rheumatology referral for complex cases
  
  

Patient Instructions:

• Take medications as prescribed
  
  

• Maintain exercise and joint protection strategies
  
  

• Follow dietary modifications for gout and metabolic health
  
  

• Report new swelling, redness, fever, or severe pain
  
  

Legal / Ethical Justification:

• Family physicians manage chronic musculoskeletal conditions to improve quality of life and prevent disability
  
  

• Documentation of therapy, counseling, and monitoring protects against medicolegal issues
  
  

• Evidence-based, individualized care ensures safe and ethical chronic pain management
  
  

Case 2p – Obesity & Metabolic Syndrome Management

Diagnosis:

• Obesity (BMI ≥30 kg/m²)
  
  

• Metabolic syndrome (central obesity plus ≥2 of the following: elevated BP, fasting glucose, triglycerides, low HDL)
  
  

Patient Presentation / Wordings:

• “I am overweight and my blood sugar and cholesterol are high.”
  
  

• “I want advice on losing weight and controlling my metabolic health.”
  
  

Examination / Assessment:

• Vital signs: BP, pulse
  
  

• Anthropometry: weight, BMI, waist circumference
  
  

• Cardiovascular assessment: heart sounds, peripheral pulses
  
  

• Labs: fasting glucose, HbA1c, lipid profile, liver function, renal function
  
  

Investigations:

• Fasting glucose, HbA1c
  
  

• Lipid profile: total cholesterol, LDL, HDL, triglycerides
  
  

• Liver function tests: screen for fatty liver
  
  

• Optional: ECG for cardiovascular risk assessment
  
  

Treatment / Prescription / Management:

A. Lifestyle Modifications (Cornerstone):

• Diet: caloric restriction, balanced nutrition, reduced refined sugars and saturated fats
  
  

• Exercise: 150 minutes/week of moderate aerobic activity + resistance training
  
  

• Behavioral therapy: goal setting, self-monitoring, stress management
  
  

• Limit alcohol and avoid smoking
  
  

B. Pharmacological Therapy (If Lifestyle Alone Insufficient):

• For weight management: Consider orlistat 120 mg PO TID with meals containing fat
  
  

• Metabolic syndrome components:
  
  

  • Hypertension: ACE inhibitors, ARBs, or other antihypertensives
    
    

  • Dyslipidemia: Statins as per guidelines
    
    

  • Hyperglycemia: Metformin or other antidiabetic agents if indicated
    
    

Expected Side Effects / Precautions:

• Orlistat: oily stools, flatulence, fat-soluble vitamin deficiency
  
  

• Statins: myalgia, liver enzyme elevation
  
  

• Metformin: GI upset, lactic acidosis (rare)
  
  

Monitoring / Follow-Up:

• Weight, BMI, waist circumference monthly
  
  

• BP at each visit
  
  

• Fasting glucose/HbA1c every 3–6 months
  
  

• Lipid profile every 6–12 months
  
  

• Monitor adherence to lifestyle interventions
  
  

Referral Criteria:

• Morbid obesity (BMI ≥40) or BMI ≥35 with comorbidities
  
  

• Failure of lifestyle and pharmacological therapy
  
  

• Consider endocrinology or bariatric surgery referral if indicated
  
  

Patient Instructions:

• Follow a structured diet and exercise program
  
  

• Track weight, waist circumference, and lifestyle habits
  
  

• Take medications as prescribed and report side effects
  
  

• Attend scheduled follow-up visits for monitoring and adjustment
  
  

Legal / Ethical Justification:

• Family physicians manage obesity and metabolic syndrome to reduce cardiovascular and metabolic complications
  
  

• Proper documentation of counseling, lifestyle interventions, and therapy protects against medicolegal issues
  
  

• Evidence-based management ensures safe, patient-centered chronic care
  
  

3. Geriatric medicine

Case 2q – Polypharmacy Review (Geriatric Patient)

Diagnosis: Polypharmacy (≥5 medications, elderly patient, risk of drug interactions)

Patient Presentation / Wordings:

• “I take many medicines and sometimes forget which ones.”
  
  

• “I feel dizzy, sleepy, or have nausea since starting new medications.”
  
  

• “I have trouble remembering which pill is for what.”
  
  

Examination / Assessment:

• Review all current medications (prescription, OTC, supplements)
  
  

• Check for drug-drug interactions, dosing appropriateness for age and renal/hepatic function
  
  

• Assess adherence and adverse effects
  
  

Treatment / Prescription / Management:

• Deprescribe unnecessary medications: gradually taper drugs that are non-essential, risky, or redundant
  
  

• Adjust doses for renal/hepatic function
  
  

• Consolidate therapy: use combination drugs if safe and evidence-based
  
  

• Medication reconciliation: provide a clear written medication schedule for patient/caregiver
  
  

Expected Side Effects / Cautions:

• Dizziness, hypotension, hypoglycemia if insulin or antihypertensives are adjusted
  
  

• Monitor for withdrawal effects if stopping CNS depressants or benzodiazepines
  
  

Monitoring:

• Blood pressure, blood glucose, renal function as per drug adjustments
  
  

• Watch for new adverse effects within 1–2 weeks after any changes
  
  

• Follow-up medication review every 3–6 months
  
  

Referral Criteria:

• Adverse reactions not manageable in primary care
  
  

• Complex drug regimens (e.g., oncology, transplant, multi-organ disease)
  
  

• Cognitive impairment affecting adherence
  
  

Patient Instructions:

• Use pill organizers or daily schedules
  
  

• Report new dizziness, confusion, or unusual symptoms promptly
  
  

• Bring all medications to each follow-up
  
  

Legal/Ethical Justification:

• Medication review and rationalization in older adults is within Family Medicine scope
  
  

• Documenting changes and monitoring ensures patient safety and medico-legal protection
  
  

Case 2r – Falls, Confusion, Dementia, Frailty

Diagnosis Examples:

• Falls in elderly (multifactorial: balance, neuropathy, medications)
  
  

• Delirium / Acute Confusion
  
  

• Dementia (Alzheimer’s type, vascular, mixed)
  
  

• Frailty syndrome
  
  

Patient Presentation / Wordings:

• “I keep tripping or falling at home.”
  
  

• “I feel weak and get tired very quickly.”
  
  

• “I forget things, appointments, or medications.”
  
  

• “I am confused about the time, place, or people.”
  
  

Examination / Red Flags:

• Gait and balance assessment
  
  

• Cognitive testing (MMSE, MoCA)
  
  

• Vital signs, orthostatic BP, vision/hearing evaluation
  
  

• Red flags: sudden confusion, infection signs, stroke symptoms → urgent referral
  
  

Treatment / Prescription / Management:

A. Falls / Frailty:

• Vitamin D 800–1000 IU orally daily
  
  

• Calcium 500–1000 mg orally daily if deficient
  
  

• Physical therapy / strength and balance exercises
  
  

• Review and adjust medications contributing to falls (antihypertensives, sedatives)
  
  

B. Delirium / Confusion:

• Identify and treat underlying cause: infection (UTI, pneumonia), electrolyte imbalance, medications
  
  

• Hydration, nutrition, orientation cues
  
  

• Avoid unnecessary sedatives; if severe agitation:
  
  

  • Haloperidol 0.5–1 mg orally or IV as short-term, low-dose (only if non-pharmacologic measures fail, monitor ECG, EPS)
    
    

C. Dementia (Mild-Moderate):

• Donepezil 5 mg orally once daily (titrate to 10 mg after 4–6 weeks if tolerated)
  
  

• Memantine 5–10 mg orally once daily (for moderate-severe cases)
  
  

• Non-pharmacologic: cognitive stimulation, caregiver support, safety measures at home
  
  

Expected Side Effects:

• Vitamin D/calcium: constipation, mild GI upset
  
  

• Haloperidol: EPS, sedation, QT prolongation
  
  

• Donepezil: nausea, diarrhea, bradycardia
  
  

• Memantine: dizziness, headache
  
  

Monitoring:

• Falls frequency, cognition, mood, nutrition, hydration
  
  

• ECG if using antipsychotics
  
  

• Liver/renal function for long-term dementia drugs
  
  

Referral Criteria:

• Acute delirium
  
  

• Recurrent falls despite intervention
  
  

• Rapid cognitive decline
  
  

• Severe frailty requiring multi-specialty management
  
  

Patient Instructions:

• Use assistive devices for walking
  
  

• Ensure safe environment at home (remove rugs, adequate lighting)
  
  

• Engage in cognitive activities
  
  

• Report new confusion, falls, or sudden weakness immediately
  
  

Legal/Ethical Justification:

• Identification and management of frailty, delirium, and mild-moderate dementia are within Family Medicine scope
  
  

• Clear referral pathways ensure patient safety and medicolegal protection
  
  

Case 2s – Pressure Ulcers / Chronic Wounds

Diagnosis Examples:

• Stage 1–4 pressure ulcer (decubitus ulcer)
  
  

• Chronic diabetic ulcer or venous stasis ulcer
  
  

Patient Presentation / Wordings:

• “I have a sore on my heel/buttocks/ankle that is not healing.”
  
  

• “The wound looks red, sometimes oozes or smells.”
  
  

• “I get pain at the wound site.”
  
  

Examination / Red Flags:

• Stage ulcer assessment (redness, skin breakdown, necrosis, infection)
  
  

• Signs of cellulitis or osteomyelitis
  
  

• Red flags: spreading infection, fever, sepsis → urgent referral
  
  

Treatment / Prescription / Management:

A. Pressure Ulcer / Chronic Wound Care:

• Wound cleaning: normal saline irrigation, gentle debridement if needed
  
  

• Topical therapy:
  
  

  • Silver sulfadiazine 1% cream for infected ulcers, apply once daily
    
    

  • Hydrocolloid / foam dressings for non-infected chronic wounds
    
    

• Pain management:
  
  

  • Paracetamol 500–1000 mg orally every 6–8 hours as needed
    
    

• Optimize nutrition: protein-rich diet, vitamin C, zinc supplementation
  
  

B. Infection Management (If signs of local infection):

• Cephalexin 500 mg orally every 6 hours for 7–10 days (mild infection)
  
  

• Refer for IV antibiotics if systemic infection or osteomyelitis suspected
  
  

Expected Side Effects:

• Silver sulfadiazine: mild local irritation, rarely allergic reaction
  
  

• Cephalexin: diarrhea, rash, GI upset
  
  

Monitoring:

• Wound size and depth weekly
  
  

• Signs of infection (redness, pus, pain, fever)
  
  

• Pain control and mobility
  
  

Referral Criteria:

• Stage 3–4 ulcers
  
  

• Suspected osteomyelitis or necrotic tissue
  
  

• Non-healing wounds >4–6 weeks despite optimal care
  
  

Patient Instructions:

• Keep wound clean and dry
  
  

• Change dressings as instructed
  
  

• Report fever, spreading redness, or increased pain immediately
  
  

• Encourage mobility and pressure relief measures
  
  

Legal/Ethical Justification:

• Management of early-stage pressure ulcers and chronic wounds is within Family Medicine scope
  
  

• Clear referral criteria protect patient safety and medicolegal interests
  
  

III. PEDIATRICS (Children & Infants)

Case 3a – Growth & Development Monitoring, Nutrition Counseling

Diagnosis: Growth and nutritional assessment in children

Patient Presentation / Wordings:

• “My child is not gaining weight as expected.”
  
  

• “He/she seems smaller than peers.”
  
  

• “I’m concerned about my child’s diet and growth.”
  
  

Examination / Assessment:

• Height, weight, BMI / weight-for-age, height-for-age
  
  

• Head circumference (infants)
  
  

• Physical examination for nutritional deficiencies (hair, skin, nails, oral cavity)
  
  

• Dietary history
  
  

Management / Prescription:

A. Nutritional Counseling:

• Balanced diet: age-appropriate calories, protein, vitamins, minerals
  
  

• Breastfeeding support for infants <6 months
  
  

• Complementary feeding from 6 months
  
  

• Supplementation if deficient:
  
  

  • Vitamin D 400 IU orally daily (infants & children)
    
    

  • Iron drops 2 mg/kg/day if iron-deficient
    
    

B. Monitoring:

• Weight, height, BMI every visit
  
  

• Growth chart plotting
  
  

• Laboratory monitoring if indicated (CBC for anemia, vitamin levels)
  
  

Referral Criteria:

• Severe malnutrition (weight-for-height <–3 SD)
  
  

• Suspected endocrinological or genetic cause
  
  

• Failure to thrive despite optimal nutrition
  
  

Patient Instructions:

• Follow diet recommendations
  
  

• Provide iron-rich foods (meat, legumes) if age-appropriate
  
  

• Return for follow-up at routine well-child visits or sooner if weight loss
  
  

Expected Side Effects:

• Vitamin D: rare hypercalcemia if overdosed
  
  

• Iron: constipation, dark stools, mild nausea
  
  

Legal/Ethical Justification:

• Growth monitoring and nutrition counseling are core pediatric primary care duties
  
  

• Referral ensures safety for severe or unresponsive cases
  
  

Case 3b – Immunizations (National & Travel-Related)

Diagnosis: Child requiring routine or travel-related vaccinations

Patient Presentation / Wordings:

• “I want my child vaccinated according to schedule.”
  
  

• “We are traveling and need extra vaccines.”
  
  

Examination / Assessment:

• Check age and previous vaccine history
  
  

• Identify contraindications (severe allergy, immunodeficiency)
  
  

Management / Prescription:

A. National Routine Immunizations: (example, may vary by country)

• BCG (birth), HepB (birth, 6, 14 weeks), DTP/Pentavalent, Polio, Hib, PCV, Measles/MR/MMR
  
  

• Provide schedule and document in vaccination card
  
  

B. Travel Vaccines (if indicated):

• Typhoid, HepA, Yellow Fever, Meningococcal, depending on destination
  
  

Monitoring:

• Observe 15–30 min post-vaccination for allergic reaction
  
  

• Monitor for fever, local redness, or swelling
  
  

Expected Side Effects:

• Mild fever, soreness at injection site
  
  

• Rare: severe allergic reaction (anaphylaxis) → emergency referral
  
  

Referral Criteria:

• Previous severe allergic reaction
  
  

• Child with immunodeficiency or serious chronic illness
  
  

Patient Instructions:

• Use paracetamol 10–15 mg/kg orally for post-vaccine fever
  
  

• Report persistent high fever, seizures, or severe swelling
  
  

Legal/Ethical Justification:

• Immunization is a core preventive pediatric service
  
  

• Documentation and counseling ensures legal and ethical compliance
  
  

Case 3c – Fever, Respiratory, Ear, Throat, Skin, GI Infections (Children)

A. Fever (General / Viral)

Diagnosis: Fever due to viral infection (common cold, viral gastroenteritis)

Patient Presentation / Wordings:

• “My child has a temperature of 38–39°C.”
  
  

• “He/she feels tired, refuses food, has a mild cough or runny nose.”
  
  

Examination / Red Flags:

• Temperature >40°C, lethargy, dehydration, difficulty breathing, convulsions
  
  

• Signs of meningitis: neck stiffness, bulging fontanelle
  
  

Management / Prescription:

• Paracetamol 10–15 mg/kg orally every 6–8 hours as needed (max 4 doses/24 h for infants)
  
  

• Hydration: oral rehydration solution (ORS) 50–100 mL/kg/day if mild dehydration
  
  

• Monitor for warning signs
  
  

Expected Side Effects:

• Rare liver toxicity if overdose
  
  

Referral Criteria:

• Persistent fever >3 days, toxic appearance, dehydration, respiratory distress, seizures
  
  

Patient Instructions:

• Give antipyretics only as needed
  
  

• Ensure adequate fluid intake
  
  

• Return if lethargy, persistent vomiting, seizures, or breathing difficulty
  
  

B. Respiratory Infections (Common Cold, Mild Pneumonia, Bronchitis)

Diagnosis:

• Viral upper respiratory infection / mild bacterial pneumonia
  
  

Patient Presentation / Wordings:

• “My child has a cough, runny nose, and sometimes mild fever.”
  
  

• “Difficulty breathing or rapid breathing during infection.”
  
  

Management / Prescription:

• Supportive care: hydration, saline nasal drops, humidifier
  
  

• Paracetamol 10–15 mg/kg orally for fever or discomfort
  
  

• Antibiotics only if bacterial infection suspected (e.g., pneumonia):
  
  

  • Amoxicillin 40–50 mg/kg/day orally in 3 divided doses for 5–7 days
    
    

Expected Side Effects:

• Amoxicillin: mild diarrhea, rash, rare allergy
  
  

• Paracetamol: rare liver toxicity if overdosed
  
  

Referral Criteria:

• Respiratory distress, hypoxia (SpO₂ <94%), inability to feed, persistent high fever
  
  

Patient Instructions:

• Give antibiotics exactly as prescribed if bacterial infection
  
  

• Monitor breathing, return if fast breathing, chest indrawing, or cyanosis
  
  

C. Ear & Throat Infections (Otitis Media, Tonsillitis, Pharyngitis)

Diagnosis:

• Acute otitis media (AOM), streptococcal pharyngitis
  
  

Patient Presentation / Wordings:

• “My child is pulling at the ear, cries, has a fever.”
  
  

• “Sore throat, refuses to eat, mild swelling of tonsils.”
  
  

Management / Prescription:

• Pain/fever: Paracetamol 10–15 mg/kg orally every 6–8 hours
  
  

• Amoxicillin 40–50 mg/kg/day orally in 2–3 divided doses for 7–10 days (first-line for bacterial AOM or strep throat)
  
  

• Supportive care: hydration, soft diet
  
  

Expected Side Effects:

• Mild diarrhea, rash, allergic reaction (rare)
  
  

Referral Criteria:

• Recurrent AOM, hearing loss, mastoiditis, severe dehydration, inability to swallow
  
  

Patient Instructions:

• Complete full antibiotic course
  
  

• Use warm compress for ear pain
  
  

• Return if worsening pain, discharge, or persistent fever
  
  

D. Skin Infections (Impetigo, Cellulitis)

Diagnosis:

• Bacterial skin infections (Staphylococcus / Streptococcus)
  
  

Patient Presentation / Wordings:

• “Red sores on face/arms/legs that are oozing.”
  
  

• “It looks crusty and itchy.”
  
  

Management / Prescription:

• Topical mupirocin 2% ointment 2–3 times daily for 5–7 days (localized impetigo)
  
  

• Oral antibiotics if extensive infection:
  
  

  • Cephalexin 25–50 mg/kg/day orally in 3 divided doses for 7–10 days
    
    

• Gentle cleansing of lesions with mild soap
  
  

Expected Side Effects:

• Topical mupirocin: local irritation
  
  

• Cephalexin: mild diarrhea, rash, rare allergy
  
  

Referral Criteria:

• Rapidly spreading infection, fever, systemic illness, non-healing lesions
  
  

Patient Instructions:

• Wash hands before and after touching lesions
  
  

• Avoid scratching
  
  

• Complete oral antibiotic course if prescribed
  
  

E. Gastrointestinal Infections (Diarrhea, Food Poisoning, Vomiting)

Diagnosis: Viral gastroenteritis / mild bacterial food poisoning

Patient Presentation / Wordings:

• “My child has watery stools, sometimes vomiting, and a mild fever.”
  
  

• “Dehydrated, less urine than usual.”
  
  

Management / Prescription:

• Hydration: ORS 50–100 mL/kg/day, small frequent sips
  
  

• Zinc supplementation: 10 mg/day (<6 months) or 20 mg/day (6+ months) for 10–14 days
  
  

• Avoid anti-diarrheal drugs in children
  
  

• Antibiotics only if bacterial dysentery suspected (bloody stools, high fever):
  
  

  • Cefixime 8 mg/kg/day orally in 2 divided doses for 3–5 days
    
    

Expected Side Effects:

• ORS: none if prepared correctly
  
  

• Zinc: mild nausea, metallic taste
  
  

• Cefixime: diarrhea, rash, allergic reaction
  
  

Referral Criteria:

• Severe dehydration, persistent vomiting, bloody diarrhea, lethargy, shock
  
  

Patient Instructions:

• Continue feeding as tolerated
  
  

• Give ORS frequently
  
  

• Return immediately if signs of dehydration (sunken eyes, lethargy, decreased urine)
  
  

Legal/Ethical Justification

• Management of common pediatric infections with supportive care and first-line antibiotics is within Family Medicine scope
  
  

• Clear referral criteria ensure patient safety and medicolegal protection
  
  

Case 3d – Worm Infestation, Dehydration, Anemia