How to prepare for ERPM (ACT 16 Exams)?

How to prepare for ERPM Medicine?

• The knowledge, attitudes and skills expected of candidates in the subject of Medicine at the ERPM are as follows:-

1. Candidates should be able to diagnose, suggest treatment and recommend preventive measures for diseases common in Sri Lanka. These include :

• • Hypertension, ischaemic heart disease, rheumatic fever, heart failure, sub-acute bacterial endocarditis, pericardial diseases.
  • bronchial asthma, chronic obstructive airways disease, TB, pneumonia, suppurative lung disease, bronchial carcinoma
  • headache, stroke, epilepsy, encephalitis, meningitis, neuropathy, myopathy, movement disorders, coma, dementias and degenerative disorders of the brain and the spinal cord.
  • viral hepatitis, chronic hepatitis, cirrhosis, upper gastrointestinal bleeding, peptic ulcer disease, malabsorption, functional abdominal pain, inflammatory bowel disease.
  • leukaemias, lymphomas, plasma cell disorders, deficiency anaemias, aplastic anaemia, haemolytic anaemias, haemoglobinopathies, platelet disorders, haemophilia and other coagulation disorders.
  • disorders of fluid and electrolyte balance, disorders of acid base balance
  • urinary tract infection, glomerulonephritis, renal failure. Thyroid disorders, disorders of calcium metabolism, diabetes mellitus.
  • rheumatoid arthritis, seronegative arthritides, SLE
  • rabies, arboviral diseases typhoid, dysentery, food poisoning, leprosy, leptospirosis, STD, malaria, filariasis
  • Thyroid disorders, disorders of calcium metabolism, diabetes mellitus.

2. Candidates should be able to recognize serious diseases in the early stages. These include:

• • Acute coronary syndromes: Myocardial infarction: STEMI, Non-STEMI, Unstable angina, Stable angina, ECG changes in ischaemic heart disease, Acute left ventricular failure, Congestive cardiac failure, Young hypertension, Hypertension and complications, Acute severe hypertension, Acute rheumatic fever, Chronic valvular heart disease; Mitral stenosis, Mitral regurgitation, Aortic stenosis, Aortic regurgitation, Mixed valvular diseases, Infective endocarditis, Ventricular fibrillation, Ventricular tachycardia, Rapid atrial fibrillation, Conduction blocks
  • Pulmonary embolism, Acute severe asthma, Chronic asthma, tuberculosis, Pneumonia and complications, Community acquired, nosocomial, in an immunocompromised pt, Poorly resolving, Bronchial carcinoma and complications, Diffuse lung diseases
  • Simple and tension pneumothorax, Pleural effusion, Type I and type II respiratory failure
  • Acute liver failure, Chronic liver failure
  • Causes of upper gastrointestinal bleeding,
  • Acute leukaemias, Lymphomas, Chronic leukaemias and, plasma cell disorders, Platelet disorders, Clotting factor, abnormalities, DIC, SDH, SAH, ICH
  • Strokes and TIAs, Meningitis, encephalitis, cerebral malaria, Causes of acute and progressive flaccid paralysis
  • Metabolic acidosis, Respiratory acidosis, Respiratory alkalosis, Hyperkalaemia, Hyponatraemia, hypocalcaemia, Acute renal failure, Chronic renal failure,
  • Acromegaly, hypopituitarism, Hyper thyroidism, Hypothyroidism, Cushing’s syndrome, Addisons disease, Other endocrine disorder
  • SLE related presentations and complications, Cerebral malaria and related complications, Dengue fever and other arboviral fevers, STD and urinary tract infections, HIV and HIV related problems and, immunocompromised states,
  • Organophosphates, Paraquat, Oleander, Paracetamol, Other common poisons
  • Venomous snakes: , Identification of venomous bites and management

3. 3. Candidates should be able to describe other diseases which illustrate important principles in medical science or are of major public importance in a global context :

• • HIV & AIDS,
  • Multiple Sclerosis
  • Pituitary disorders, Addison’s, Cushing’s and Conn’s syndromes
  • Myasthenia gravis.

4. Candidate should be abel to describe and recognize Diseases/conditions that can be prevented and/or controlled by change in behaviour of the patient or by immunisation :

• • Non communicable disease e.g. diabetes mellitus; vascular diseases; alcoholic liver disease; COAD; bronchial carcinoma; anaemias; metabolic syndrome
  • Communicable diseases: TB, Dipththeria, Pertussis (whooping cough), Tetanus, Poliomyelitis, Measles, Rubella, viral hepatitis; H1N1 Influenza, Dengue, HIV and other STDs
  • Genetic diseases
  • Malnutrition
  • Candidates should know the Immunisation schedule used in Sri Lanka.

5. Counseling Candidates should show the ability to counsel patients and their relatives when necessary. Demonstrate knowledge of communication skills and basic managerial and administrative skills required  to function efficiently in a hospital ward setting.
6. Candidates should be able to describe and carry out the following procedures:

• • obtaining a sample for blood culture
  • ophthalmoscopy
  • lumbar puncture
  • paracentesis (abdominal and thoracic)
  • urethral catheterization
  • naso-gastric and gastric intubation.

7. Recommended reading for Medicine

• 1. Clinical Medicine (6th ed) by Parveen Kumar & Michael Clark
  2. Davidson’s Principles and Practice of Medicine (20th ed) by Nicholas A Boon, Nicki R
  3. Colledge, Brian R Walker & John AA Hunter
  4. McLeod’s Clinical Examination (10th ed) by John F Munro & Ian W Campbell (editors)

How to prepare for ERPM Pediatrics?

 1 Candidates should be able to:

• • describe the normal development of the fetus, and factors that affect fetal growth.
  • Identify common congenital abnormalities and their causes and consequences.
  • explain the principles of infant nutrition including breast feeding, weaning and recommended diets for infants specifying food items
  • Compare human and cow milk and the advantages of human milk
  • recognise the normal pattern of growth and causes and management of abnormalities – such as failure to thrive, obesity, short and tall stature.
  • describe the normal development of the infant and preschooler and recognize deviations from the normal
  • take a good Paediatric clinical history, identify important information in the patients history and be able verify whether information is correct. Interpretation of investigation results according to the clinical situation, and familarity with common invasive and non invasive diagnostic investigations.
  • describe the epidemiology of common communicable diseases seen among children in Sri Lanka and explain their  pathophysiology, clinical features, management and prevent ion.
  • e.g. acute gastro-enteritis, respiratory tract infections, hepatitis, meningitis, encephalitis, typhoid, tuberculosis, leptospirosis, whooping cough, measles, rubella, and mumps.
  • describe common and important congenital heart diseases and acquired heart diseases eg , rheumatic fever and Kawasaki disease – including their aetiology, clinical presentation and management
  • recognize and manage acute respiratory infections including bronchiolitis bacterial pneumonia, stridor and upper respiratory infections. Describe and recognize X ray changes seen in common respiratory conditions of children. With reagard to bronchial asthma – describe its triggers, prevention, assessment of severity and treatment options.
  • describe lung function tests and their practical use.
  • with regard to non communicable diseases in the paediatric age group in Sri Lanka _ Identify common conditions such as acute post streptococcal glomerular nephritis, nephrotic syndrome, malnutrition, bronchial asthma, urinary tract infections, thalassaemia haemophilia, acute flaccid paralysis, cerebral palsy, mental retardation, and epilepsy.- and be able to diagnose, treat, prevent and advice on prognosis of such conditions.
  • Identify the common nutritional problems in Sri Lanka.e.g. protein energy malnutrition, iron deficiency, iodine deficiency, Vitamin A deficiency & other micro nutrient deficiencies, know their predisposing causes, presentations, andmanagement, including available food supplements and principles of nutrition therapy and rehabilitation.
  • explain the pathophysiology, identify clinical features and complications, describe the management and prevention of neonatal problems common in Sri Lanka e.g. low birth weight, preterm births, respiratory distress, jaundice,  sepsis including umbilical sepsis, meningitis and septicaemia, hypothermia, hypoglycaemia, hypocalcaemia, seizures and surgical problems.
  • describe the Principles and practical aspects of resuscitation of an asphyxiated newborn
  • describe common renal, endocrine and metabolic disorders including hypothyroidism, diabetes mellitus and inborn errors of metabolism. .
  • describe common haematological conditions especially deficiency anaemias, haemolyitic anemia ( especially Thalassaemia) , immune thrombocytopenic purpura, haemophilia, aplastic anaemias and haematological malignancies.
  • diagnose and manage common dermatological conditions in childhood e.g. eczema, scabies, impetigo, dematophytes, and head lice.
  • diagnose common psychiatric disorders in childhood.e.g. autism, ADHD, enuresis, tantrums, enuresis and other paediatric psychiatric disturbances.
  • describe and diagnose common childhood malignancies – especially leukaemias and common solid tumours
  • diagnose and manage burns and common surgical problems of infants and children including hyoertrophic pyloric stenosis, intususseption and volvulus:
  • describe and recognize genetically acquired diseases and chromosomal abnormalities, including inheritance patterns, show familiarity with pedigree charts, and assessment of risks of affection. Also, describe the clinical features of common genetic diseases, prevention and treatment modalities available for such diseases.
  • describe the current morbidity and mortality patterns in paediatrics in Sri Lanka including changes and improvements as well as the underlying causes and interventions.
  • Describe the x-panded program of immunization( EPI) in Sri Lanka, the sites and routes of administration of vaccines, and adverse effects which may follow immunization. Also, describe vaccines and their storage for both EPI  and important non EPI vaccines.
  • define Issues relating to child rights and child protection, and presentations of child abuse including physical, emotional and sexual abuse.
  • counsel parents in the event of a child’s death or when a child has a serious illness or disability and break bad news to them.
  • Show familiarity with cultural habits, misbeliefs, and alternative healing methods practised by Sri Lankan people, and how to plan treatment options taking into consideration buying capacity of patients when possible.
  • calculate perinatal mortality rate, infant mortality rate and child mortality rate and be able to describe the trends shown in the recent past in Sri Lanka, and how these figures are important in policy planning. Describe other important demographic data in Sri Lanka such as birth rate, immunization coverage pertaining to child health.
  • Show awareness of Importance of road traffic and home accidents and poisonings- both accidental and intentional, especially paracetamol poisoning. Animal bites including dog bite and snake bite, complications and management.
  • Show awareness of environmental hazards such as air pollution and mosquito borne diseases and their impact on child health, diseases caused and their prevention and control.
  • show familiarity with and describe the management of common paediatric emergencies such as stridor, anaphylaxis, sever dehydration and hypovolaemic shock, dengue shock syndrome, cardiac failure, status epilepticus,status asthma and diabetic ketoacidosis.

2. Recommended Reading for Paediatrics :

• • Hospital Paediatrics (3rd ed) by Anthony D Milner & David Hull, 1998
  • Illustrated Paediatrics – (3rd ed) by Tom Lissauer, Graham Clayden
  • A Neonatal Vade Mecum (3rd ed), B Spiedel (ed), 1998
  • A Paediatric Vade Mecum (14th ed) TG Barrett, AD Lander, V Diwakar, 2003
  • A manual of neonatal intensive care (4th ed) JM Rennie and NRC Robertson, 2002
  • Nelson’s Textbook of Paediatrics (18th ed) RM Kliegman et al, 2007

How to prepare for ERPM Surgery?

1 The candidate should be :

• • able to obtain a comprehensive history and elicit and interpret physical signs of a surgical patient
  • able to arrange appropriate investigations and be able to interpret them
  • able to to arrive at a probable diagnosis and rationlise a treatment strategy and pre and post-operative care
  • familiar with the spectrum of surgical care available and be able to assess the risks and benefits
  • able to understand the principles of management of critically injured patients and other surgical emergencies
  • explain in simple terms the intended surgical procedure and be able to obtain informed consent
  • emphasise the important ethical ,moral and social issues involved in surgical practice and to induce a discussion on cost benefit analysis
  • perform simple basic essential surgical procedures
  • demonstrate a kind and caring attitude towards patient care
  • be able to describe the etiology pathogenesis and complications of the following disease states.

2  The candidate should be able to diagnose and describe management of:-

• • hernias ( inguinal, femoral, Para umbilical, umbilical, epigastric & incisional)
  • scrotal lumps (hydrocoeles, cyst of the epididymis, spermatocele, varicocele    & epididymo – orchitis)
  • acute appendicitis, appendicular mass & abscess
  • breast lumps (fibroadenomas, fibroadenosis & carcinomas)
  • fissure in ano, fistula in ano, ischiorectal abscess, haemorrhoids, perianal haematoma
  • varicose veins
  • deep vein thrombosis and pulmonary embolism
  • lymphoedema and other lymphatic disorders
  • goitres and other neck lumps (thyroglossal cyst, branchial cyst, cystic hygromas & carotid body tumour)
  • thyrotoxicosis and hypothyroidism
  • thyroid Cancers
  • parathyroid adenomas, hyperparathyroidism and hypoparathyroidism
  • haematemesis and oesophageal varices
  • dysphagia (achalasia and oesophageal cancer)
  • peptic ulcers and gastric cancers
  • acute and chronic pancreatitis
  • cancers of the pancreas
  • liver cysts, tumours and abscess
  • cholecystitis, biliary calculous disease and obstructive jaundice
  • salivary glands – calculi, infections and neoplasms
  • cancers of mouth, tongue, pharynx and larynx
  • rectal bleeding, colorectal cancer and anal cancer
  • diverticular disease, and Inflammatory bowel disease
  • intestinal obstruction
  • peritonitis
  • haematuria, urinary tract infections, urinary tract calculi, hydronephrosis
  • bladder outflow obstruction, benign hypertrophy of prostrate and cancer of the prostate
  • urethral strictures
  • cancers of the penis and testis
  • renal cysts and renal tumours
  • acute and chronic limb ischaemia
  • diabetic wounds
  • abdominal aortic aneurysm, A-V malformations and A-V fistulas
  • skin infections (abscess, cellulitis, erysipelas, carbuncles, gas gangrene)
  • skin pre malignant and malignant conditions
  • fractures, osteomylitis and tumours
  • common paediatric surgical problems – e.g. cleft lip / palate, tracheo-oesophageal fistula (TOF), pyloric stenosis, phimosis, posterior urethral (PU) valves, hypospadias, congenital dislocation of hip (CDH), scoliosis, club foot, slipped upper femoral epiphysis,and congenital herniae
  • raised intracranial pressure and space occupying lesions (SOL)
  • eye injuries, retinal detachment, cataract and conjunctivitis
  • chronic otitis media and sinusitis

3   The candidate should be able to :-

• • manage cases of trauma (mass disaster, triage, according to Advance Trauma Life Support (ATLS) guidelines, head injury, chest injury, abdominal injury; blunt and penetrating, liver lacerations and  splenic rupture, injury to major blood vessels, spinal injuries, burns)
  • perform pre-operative assessment and preparation
  • perform post-operative assessment and management after surgery of fever, nutrition, pain, urine output, and pulmonary atelectasis
  • manage drains
  • prescribe prophylactic and therapeutic antibiotics in surgery
  • describe issues related to HIV infection and Hepatitis B infection in surgery..
  • describe the principles of renal, lung, liver, and bone marrow transplantation.
  • describe the management of surgical emergencies e.g. surgical airways
  • describe technique of emergency IV access.
  • perform and describe cardio pulmonary resuscitation (CPR)
  • perform and describe insertion of intercostal tube and describe management of the IC tube
  • manage oliguria and anuria
  • manage hepato renal syndrome
  • describe the incidence of common malignancies in Sri Lanka

4  Recommended Reading for  Surgery :

• • RCN Williamson & BP Waxman. Scott: An Aid to Clinical Surgery (6th ed), 1998
  • H Ellis, R Calne & C Watson. Lecture Notes on General Surgery (11th ed). 2006
  • GR McLatchie & DJ Leaper. Oxford Handbook of Clinical Surgery (2nd ed) 2002
  • NL Browse. An introduction to the symptoms and signs of surgical disease (4th ed), 2005
  • A Clain (editor). Hamilton Bailey’s Demonstration of Physical Signs in Clinical Surgery (17th ed). 1986
  • RCG Russell et al (editors). Bailey & Love’s Short Practice of Surgery (24th ed). 2004
  • PJ Morris & WC Wood (editors). Oxford Textbook of Surgery Volumes 1, 2 & 3 (2nd ed). 2000
  • Mohan de Silva. Clinical Surgery made Easy. A companion to problem based learning (1st Edition) September 2008

How to prepare for ERPM OBG?

• Obstetrics:The student should be competent to prevent, recognize, diagnose and manage normal and abnormal pregnancy, labour and puerperium. 
  • Normal Pregnancy: anatomy & physiology of the female reproductive system, anatomical &  physiological changes in normal pregnancy, fetal physiology, pre-pregnancy counselling, diagnosis & duration of the normal pregnancy, placenta & fetus (development & functions), prenatal care, course & mechanism of normal labour & delivery, puerperium, nutrition in pregnancy.
  • Pregnancy complicated by:- abnormalities of the pelvic organs such as congenital deformities of the uterus and the vagina, uterine fibroids, ovarian tumours, miscarriage, gestational trophoblastic disease, ectopic pregnancy, antepartum haemorrhage (placenta praevia, abruptio placentae, vasa praevia ), polyhydramnios and oligohydramnios, multiple  pregnancy , breech presentation, malpresentations, malpositions, prematurity and post maturity , pre-labour rupture of membranes, intrauterine growth restriction, intrauterine death, fetal anomalies.
  • Labour complicated by: prolonged labour, obstructed labour, breech presentation, face and brow presentation, shoulder presentation, transverse lie, oblique lie, occipito-posterior position, pelvic abnormalities and cephalopelvic disproportion, fetal distress, cord prolapse, postpartum haemorrhage, retained placenta.
  • Puerperium complicated by: obstetric shock, infections, thrombophlebitis, lactational problems and breast abnormalities (engorgement, cracked nipples, acute puerperal mastitis, breast abscess, suppression of lactation, galactocoele), mood disorders (puerperal blues and depression).
  • Medical disorders: pregnancy induced hypertension, gestational diabetes mellitus, anaemia and nutritional deficiencies, Rhesus isoimmunization, coagulation disorders, thromboembolic disease, heart diseases, hepatitis, respiratory diseases, renal diseases, epilepsy, thyroid dysfunction, urinary tract infection, upper respiratory tract infections, gastro enteritis, reflux oesophagitis.
  • Traumatic lesions, operative and diagnostic procedures: rupture of the uterus, acute inversion of the uterus, perineal lacerations, fistulae, haematoma of broad ligament and vulva, maternal nerve injuries, caesarean section, forceps delivery, vacuum delivery, breech delivery, twin delivery, manual removal of placenta, repair of perineal tears, induction of labour by artificial rupture of membranes and oxytocin, ultrasonography, monitoring of fetal wellbeing, cardiotocography, prenatal diagnosis

2. Gynaecology: The candidate  should be competent to prevent, recognize, diagnose and manage common gynaecological problems and diseases.

• • normal development of the female genital tract, abnormalities in the genital tract, disorders of sexual development.
  • Genital tract Infections:- bartholinitis, vulvitis, vaginal discharge, nonspecific vaginitis, acute and chronic cervicitis, endometritis, pelvic inflammatory disease, TB of the genital tract, chlamydia, gonorrhoea, syphilis, herpes genitalis, papilloma virus infection.
  • Benign tumours in female genital tract:- cysts of the vulva and vagina, fibromyoma, cervical and endometrial polyps, benign tumours of the ovary, endometriosis, adenomyosis.
  • Premalignant and malignant tumours:- cervical intraepithelial neoplasia, endometrial hyperplasia, gestational trophoblastic tumours, vulval carcinoma, vaginal carcinoma, cervical carcinoma, endometrial carcinoma, uterine sarcoma, ovarian malignancies, carcinoma of the fallopian tubes.
  • Menstrual disorders:- primary and secondary amenorrhoea, oligomenorrhoea, menorrhagia, dysfunctional uterine bleeding, postmenopausal bleeding and intermenstrual bleeding, premenstrual tension, dysmenorrhoea.
  • Infertility and contraception:- primary and secondary infertility, treatment methods available, hormonal contraception, intrauterine contraceptive device, tubal sterilization.
  • Urogynaecology disorders:- genuine stress incontinence, detrusor instability, mixed incontinence, genital tract injuries and fistulae, genital prolapse, retroversion of the uterus.
  • Endocrine disorders:- precocious puberty, normal and delayed puberty, intersex, hyperprolactinaemia, polycystic ovarian disease, hirsutism, climacteric symptoms and menopause.
  • Operative and diagnostic procedures:- dilatation and curettage, evacuation of uterus, biopsy, cauterization, abdominal and vaginal hysterectomy, tubal surgery, cystectomy, stress repair, myomectomy, laparoscopic surgery, hysterosalpingography, ultrasonography, cervical smear.

3. Recommended Reading for Obstetrics and Gynaecology :

• • Philip N Baker (editor). Obstetrics by Ten Teachers (18th ed). London, Hodder Arnold, 2006
  • Ash Monga (editor). Gynaecology by Ten Teachers (18th ed). London, Hodder Arnold, 2006
  • Hiralal Konar (editor). Textbook of Obstetrics by DC Dutta (6th ed). Calcutta, New Central Book Agency, 2004
  • Hiralal Konar (editor). Textbook of Gynaecology by DC Dutta (4th ed). Calcutta, New Central Book Agency, 2003
  • J Oats, S Abraham (editors). Llewelyn Jones’ Fundamentals of Obstetrics & Gynaecology (8th ed). Edinburgh, Elsevier-Mosby, 2005
  • Michael Swash (editor). Hutchison’s Clinical Methods (22nd ed). Edinburgh, Elsevier Science 2007.
  • S Arulkumaran, I Symands, A Fowlie (editors). Oxford Handbook of Obstetrics & Gynaecology (1st ed) Oxford, Oxford University Press, 2004
  • DK Edmonds (editor). Dewhurst’s Textbook of Obstetrics & Gynaecology (7th ed). Oxford, Blackwell Publishing, 2007
  • CN Piercy. Handbook of Obstetric Medicine. (3rd ed). Andover, Hampshire, Taylor & Francis, 2006.

How to prepare for ERPM Psychiatry?

1 The candidate should be able to:

• • describe the common psychiatric conditions encountered in Sri Lanka
  • obtain a relevant history and conduct a mental state examination with a view to arriving at a differential diagnosis.

2. The candidate should possess knowledge, skills and attitudes to manage and refer as necessary for further opinion and care, the common psychological conditions presenting to a primary care physician

• • Psychotic illnesses (schizophrenia, affective disorders, delusional disorders, brief psychotic episodes).
  • Organic psychiatric illness (delirium, dementia, epilepsy related psychiatric disorders).
  • Patients who presents after deliberate self-harm.
  • Neurotic stress related disorders (anxiety disorders, phobia, obsessive compulsive disorder and dysthymia, adjustment disorder, somatoform and dissociative disorders).
  • Substance misuse (eg. alcohol, cannabis, heroin)
  • Sexual dysfunction (eg. erectile dysfunction, premature ejaculation, vaginismus, general lack of desire)
  • Puerperal psychiatric disorders.
  • Normal and abnormal grief reaction.
  • Psychiatric ailments encountered in childhood (eg.conduct disorder, emotional disorders, learning disabilities, pervasive developmental disorders, attention deficit disorders).
  • Suicide risk assessment, brief supportive psychotherapy, motivational interview, conduct family meetings, liaison of agencies relevant to the care of the patient.
  • Screening for alcohol dependence,

3. The candidate should be able to work out the differential diagnosis and management of common psychiatric emergencies such as acute dystonic reactions, neuroleptic malignant syndrome, lithium toxicity, delirium, seizures, suicidal behaviour, depressive stupor, intoxication due to alcohol and drugs,  an agitated patient, violent and homicidal behaviour
4. Recommended Reading for Psychiatry :

• • Shorter Oxford Textbook of Psychiatry (5th ed or latest) by Michael Gelder, Richard Mayou & Philip Cowen
  • Psychiatry (3rd ed or latest) by Michael Gelder, Richard Mayou & John Geddes (Oxford Core Text Series)
  • Concise Texbook of Clinical Psychiatry (2nd ed or latest) by Benjamin J Sadock & Virginia A Sadock
  • Oxford Handbook of Psychiatry by Semple, Smyth, Burns, Darjee, McIntosh (Latest edition)
  • Lecture Notes in Psychiatry (8th ed or latest) Paul Harrison, John Geddes & Michael Sharpe

How to prepare for ERPM Forensic Medicine?

1. Candidates should be able to describe:

• • The medico-legal framework in the country and the duties required of a medical officer within this system while working in the roles of an intern medical officer, an officer in the out-patient department of a hospital, a house officer of a ward as a medical officer in medico-legal work, as a General practitioner as a Specialist in Forensic medicine, and as a doctor working in any other capacity.
  • Inquests – Definition, types of deaths that require an inquest, procedure of the inquest, appointment and powers of Inquirer into sudden death, doctor’s role in the inquest, judicial and pathological post mortems, dying declaration, dying deposition
  • Changes after death – Definition of death, classification of changes after death, hypostasis, rigor mortis, putrefaction, adipocere, mummification. Estimation of time since death: eye changes, cooling, hypostasis, rigor mortis and putrefaction, cessation of bodily functions, circumstantial factors, forensic entomology.
  • Injuries – Definition, characteristic features, mechanism of producing injuries of abrasions, contusions, lacerations, incised injuries, stabs, fractures, effects of injury and cause of death, circumstances of injury (accident /suicide / homicide), injury patterns, defense, self-inflicted and fabricated injuries, injuries due to falls, medico-legal importance of injuries, healing of injuries, antemortem and postmortem injuries, Interpretation of injuries and determination of the features of weapons producing injuries. Regional injuries: face, head, neck, chest, abdomen, pelvis, spine, limb.
  • Categories of hurt – non-grievous hurt, grievous hurt (section 311 penal code), endangering life, fatal in the ordinary course of nature, necessarily fatal injuries, Medico-legal Examination form and Medico-legal report
  • Autopsy examination and report writing, dissection procedures in special circumstances eg neck, face, pelvic dissection, musculoskeletal, spinal cord, suspected thromboembolism, pneumothorax, air embolism,Death certification and cause of death according to the WHO format, declaration of death
  • Road traffic and train accidents – Injuries and injury patterns seen in pedestrians such as primary impact, secondary impact, secondary and run-over injuries, vehicle occupants, motor cyclists, pedal cyclists, three wheeler injuries, protective devices in vehicles, injuries caused by a moving train
  • Firearm injuries: basic types and parts of gun, mechanism of firing, smooth bore and rifled weapons, mechanisms of causing of injury, entrance wound, exit wound, estimation of approximate range, identification of weapons, direction of firing, atypical features of gunshot wounds.
  • Death from explosives: types of explosives devices, mechanisms of injury, injury patterns, post mortem examination, investigation of mass disasters to include procedure, requirements for conducting a medico-legal investigation, the role of the Forensic pathologist in a major disaster
  • Injuries and effects of physical agents – heat, cold, electricity, lightning eg Types of burns, effects and sequelae, degree of burns and categorization, medico-legal issues in a burnt body, antemortem and postmortem burns, hypothermia and hyperthermia, features, effects, sequelae and circumstances of electrocution, mechanisms and causation of death, injuries due to lightning and medico-legal investigation
  • Sudden natural death – Definition, causes in different systems, negative autopsy and establishing the cause of death, autopsy findings in starvation and neglect
  • Identification of the living and dead – medico-legal importance, general and specific methods of identification, clothing and personal effects, scars, stigmata, tattoos, deformities, disease, primary identifiers, determination of age, sex, stature, examination of skeletal remains, forensic odontology, exhumation and excavation of mass graves
  • Criminal abortion – law of Sri Lanka and developments in other countries, types and methods of abortion, spontaneous abortion as a differential diagnosis, objectives of the medico-legal examinations, reporting on evidence of recent pregnancy and delivery, evidence of abortion and evidence of interference, cause of death.
  • Sexual offences – law of sexual offences and related offences, medico-legal investigation of a victim of sexual abuse to include history, examination, sample collection and investigation, referrals, follow up and report writing, examination of an alleged assailant, medico-legal examination in child sexual abuse, unnatural offences
  • Infanticide – Definition, objectives of medico-legal investigation, stillbirths and natural infant deaths as a differential diagnosis, viability, establishment of maturity, signs of live birth, signs of recent delivery, modes of infanticide, autopsy examination and investigation in a suspicious infant death, examination of alleged mother and referral to psychiatrist.
  • Child abuse and Sudden Infant Death Syndrome (SIDS) – Definition, laws in Sri Lanka, types of abuse, features and injuries seen in child abuse, differential diagnosis, medico-legal investigation and management of suspected child abuse, autopsy findings in child abuse, definitions, possible aetiologies and autopsy examination in SIDS
  • Torture and battering – Definition, methods of torture, identification of injuries, injury patterns and scars in torture and report writing, modes of presentation, weapons used, investigation of a death in custody, wife battery, abuse of domestic servants, cause of death.
  • Asphyxia – Definition, types and circumstances of death, general features of asphyxia, medico-legal investigation to include history, scene visit, post mortem examination and investigation in smothering, gagging, choking, overlaying, hanging, manual and ligature strangulation, traumatic asphyxia, postural asphyxia and sexual asphyxia
  • Drowning and immersion in water – Definition, features, circumstances, types of drowning, investigation of a body recovered from water.
  • Scene of crime, collection of samples and chain of custody – Definition, importance of scene visit, investigation, recording and collection of evidence at a scene, Locard’s principle and its use at a scene, role of the Forensic Pathologist at a scene of crime, despatch of body to the mortuary, examination of blood and other stains, use of blood in disputed paternity, DNA profiling, collection of samples and maintanence of chain of custody in medico-legal work.

2. With regard to Forensic Toxicology the candidate should be able to describe:-

• • Definitions, routes of administration and elimination, actions, factors affecting outcome, diagnosis, principles of management, autopsy, sending specimens for analysis, classification of poisons, circumstances of poisoning (accident, suicide, homicide), sources, preparations, properties, circumstances of poisoning, basic mechanism of action, basic clinical and pathological stages and post mortem appearance.
  • List the common poisons in Sri Lanka. Agro-chemicals (insecticides, rodenticides, weedicides), organophosphorous compounds, organo-chlorate compounds, carbamates, paraquat, diquate. Corrosive poisons: acids, alkali. Alcohol:  methyl alcohol, ethyl alcohol, investigation of a death due to alcohol
  • Plant poisons:  Definition and classification:  atropine, strychnine, modecca palmate, Gloriosa superba, Manioc, other common plant poisons.  Metal poisons : lead, arsenic, mercury, copper, (cyanide). Anti-narcotic legislation:  heroin, opium, cannabis Barbiturates, phenothiazines, salicylates Other poisons:  carbon monoxide, ammonia and other poisonous gases, phenol. Ethical and medical issues in poisoning

3. Candidates should be able to describe the medico-legal aspects of alcohol and addictive drugs, alcoholic beverages, absorption, metabolism and actions on the body, stages and intoxication, examination, and reporting on drunkenness, criteria in diagnosing drunkenness, differential diagnosis of drunkenness, completion of medico-legal examination form and medico-legal report in drunkenness.
4. Candidiates should be able to give an account of the legal system in Sri Lanka: Magistrates Court, Primary Court, District Court, High Court, trial by jury, Court of Appeal, Supreme Court, Tribunals, Commissions, Attorney General’s Department. Medical evidence:  Evidence Ordinance, Oral and documentary evidence, preparation of reports, giving oral evidence in court, doctor as an expert witness.

5. The candidate should be able to describe:

• • Basic medical ethics – consent and its types and uses, professional secrecy and privileged communications, consent and its various features, professional misconduct.
  • Medical negligence – criminal and civil medical negligence, definition of negligence, causation, damages, standard of care, accepted practice, burden of proof, Res lpsa Loquitur, Defenses, malpractice litigation, common defences by the Practitioner.
  • Forensic psychiatry: Criminal responsibility, testamentary capacity, fitness to plead, fitness to stand trial, detention of mentally ill patients, guardianship of mentally ill patients.
  • Industrial accidents and compensation: Doctor’s duties, procedure in claiming compensation, assessment of disability.
  • The Sri Lanka Medical Council – Members and office bearers, powers and duties of the Council, categories of registration, procedure in obtaining registration, rights and privileges of registered persons, disciplinary proceedings, Preliminary Proceedings Committee, Professional Conduct Committee, Erasure.

6. Recommended reading for Forensic Medicine:

• • Keith Simpson’s Forensic Medicine (edited by Bernard Knight),
  • Lecture Notes in Forensic Medicine (Vols I & II) – Dr. L.B.L. de Alwis,
  • Forensic Medicine and Medical Law – Dr. Hemamal Jayawardena,
  • Clinical Forensic Medicine edited by W.D.S. Mc Lay.

How to prepare for ERPM Emergency Medicine?

1. Candidates should be able to recognize medical emergencies from history, examination and investigations; deal effectively with such emergencies at different levels (including resuscitation and management), and demonstrate detailed knowledge on how to perform life-saving procedures.
2. They should have clinical experience and be able to describe the management of the following:-  

• • Acute chest pain, acute pulmonary oedema, congestive cardiac failure, cardiac arrhythmias, cardiac arrest, cardiogenic shock, hypertensive encephalopathy, massive pulmonary embolism, cardiac tamponade.
  • Acute respiratory failure, acute severe asthma, tension pneumothorax, massive pulmonary collapse, acute laryngeal obstruction, epistaxis.
  • Upper gastro-intestinal bleeding, hepatic encephalopathy, acute pancreatitis, typhoid perforation, severe diarrhoea and dehydration, electrolyte imbalance.
  • Unconsciousness, status epilepticus, meningitis, viral encephalitis, stroke, subarchnoid haemorrhage, intracranial hypertension, bulbar paralysis, respiratory muscle paralysis, myasthenia gravis, Guillain Barre syndrome,
  • Acute renal failure.
  • Acute disseminated intravascular coagulation, acute massive intravascular haemolysis.
  • hypothermia, heat stroke, electric shock, near drowning,
  • Dengue haemorrhagic fever
  • Diabetic keto-acidosis, hypoglycaemic coma, thyrotoxic crisis, myxoedema coma, acute adrenal Insufficiency, acute hypopituitarism, tetany, acute hypercalcaemia, acute water intoxication.
  • Acute poisoning
  • Acute Organic Psychoses
  • Shock
  • Complicated Falciparum malaria
  • Snake Bite,
  • Rabies

2. Candidates should be able to describe the management of common paediatric emergencies such as :

• stridor
• anaphylaxis
• severe dehydration
• hypovolaemic shock
• dengue shock syndrome
• cardiac failure
• status epilepticus
• status asthma
• diabetic ketoacidosis

How to prepare for ERPM Pathology?

• With regard to general pathology, the candidate should be able to:
  • identify causative agents and predisposing factors of disease. This would include including pathogenic organisms, physical and chemical agents, cigarette smoking, alcohol, nutritional, metabolic, immune-related, environmental, genetic and age-related factors.
  • describe the different mechanisms through which the above factors produce disease.
• This would include

• • Reversible and irreversible cellular injury – fatty change, necrosis, apoptosis, infarction and gangrene
  • Acute and Chronic inflammation –cellular and vascular response, chemical mediators, pathogenesis and cells in chronic granulomatous and immune-mediated inflammation, with special emphasis on Tuberculosis, systemic effects of inflammation and complications and sequelae of inflammation
  • Abnormalities of the blood and vascular system – hemorrhage, thrombosis, embolism. oedema and chronic venous congestion
  • Adaptive response of tissue to injury – hypertrophy, hyperplasia, hypoplasia, atrophy, metaplasia, dysplasia and in-situ carcinoma
  • Healing of tissue following injury – factors which influence healing by resolution, regeneration and repair, primary and secondary wound healing, factors that impair healing, and fracture healing
  • Neoplasia – principles of nomenclature, differences between benign and malignant tumours, spread of tumours, clinical effects of tumours, paraneoplastic syndromes, grading and staging, laboratory diagnosis of tumours and the genetic basis of malignancy including oncogenesis and cancer-related genes
  • Other parenchymal and interstitial responses and biochemical abnormalities – pigmentation, calcification, amyloidosis, and acidbase balance
  • describe the alterations in structure and function of tissues and organs in the body at a macroscopic level as a result of the above mechanisms and thus be able to explain the different clinical symptoms and signs that arise.
  • link the basic mechanisms of Pathology learnt at a foundation level to specific diseases and disease entities of the cardiovascular. respiratory, gastro-intestinal, genitor-urinary, neurological, musculo-skeletal and lympho-proliferative systems in order to explain their pathogenesis, clinical features, complications and effects.
  • select the appropriate investigations and specimens required to identify the pathogenic mechanism and the aetiological agents and be able to describe aware of accepted methods of specimen handling and transport

2. With regard to haematology, the candidate should be able to :

• • Define anaemia and be aware of the normal ranges of Haemoglobin for newborns, infants, adult males and females (pregnant and non-pregnant)
  • Outline the main cause, pathogenesis and clinical effects of anaemia and be able to list relevant investigations.
  • State principles of treatment and outline measures used in their prevention.
  • Describe different categories of anaemia such as
  • iron, folate and B12 deficiency anaemias
  • inherited and acquired haemolytic anaemias, including immune and non-immune types
  • anaemia of chronic disease

3. With regard to haemato-oncology the candidate should be able to describe the pathology of :

• • Acute leukaemia
  • Myeloproliferative disorders
  • Lymphoproliferative disorders
  • Multiple Myeloma

4. With regard to bone marrow failure syndromes, the candidate should be able to describe:-

• • Aplastic anaemias
  • Myelodysplastic syndromes

5. With regard to normal haemostasis and the investigation and management of bleeding disorders, the candidate should be able to describe :

• • coagulopathies,
  • Platelet function disorders and
  • thrombocytopaenias
  • the aetiology, investigation and management of thrombophilia

6. With regard to blood transfusion the candidate should :-

• • Have performed or observed blood grouping, cross matching,
  • preparation and/or use of blood components,
  • be able to describe haemolytic disease of the new born,
  • be able to describe the investigate and management of hazards of blood ,
  • transfusion and their prevention.

7. Recommended Reading for Pathology :

• • Basic Pathology by Stanley L Robbins, 7th Edition
  • Consise Pathology by Parakrama Chandrasoma . 3rd Edition
  • Pathalogical basis of Disease by Stanley L Robbins.
  • Essential Haematology by Hoffbrand and Petit (latest Edition)
  • Practical Haematology by Dacie, Lewis and Bain (latest Edition)

Also Read:

1. ERPM (ACT 16 Exams)
2. Guidelines to prepare for ERPM (ACT 16 Exams)

Also Watch:

• Community medicine theory 1 MCQ discussion from the youtube channel “ERPM Sri Lanka”

• ERPM Pediatric emergency viva from the Youtube channel “Dr V & A Health tips”

Also read:

1. ERPM @ SLMC Website