Master Adult Health (Medicine)
for AMC Cat 1

Core Concepts

Adult Health (Medicine) demands a systematic, patient-centred approach. Prioritize life-threatening conditions. Understand common risk factors (smoking, obesity, hypertension, diabetes, hyperlipidaemia) for chronic diseases. Recognise the atypical presentation of diseases in the elderly. Focus on pathophysiology, epidemiology, and evidence-based guidelines. Always consider patient comorbidities and polypharmacy when assessing and managing.

Clinical Presentation

• Chest Pain: Differentiate cardiac (e.g., ACS: retrosternal, radiating to arm/jaw, exertional, diaphoresis, dyspnea) from non-cardiac (pleuritic, positional, palpation-reproducible, reflux). Always rule out ACS, Pulmonary Embolism (PE), and Aortic Dissection.
• Dyspnea: Acute vs. chronic. Consider cardiac (Heart Failure, ACS), respiratory (asthma, COPD, pneumonia, PE, pneumothorax), metabolic (DKA, severe acidosis), and severe anaemia. Assess oxygen saturation immediately.
• Fever (FUO): Infection (bacterial, viral, fungal, TB, endocarditis), inflammation (autoimmune, vasculitis), malignancy (lymphoma, leukaemia). Thorough history and examination are key for source identification.
• Altered Mental Status (AMS): AEIOU TIPS mnemonic: Alcohol/Abuse, Epilepsy, Insulin, Overdose, Uremia, Trauma, Infection, Psychosis, Stroke/Shock. Assess GCS, pupil reactivity, and motor response.
• Abdominal Pain: Location, character, radiation, associated symptoms guide differential. Common: Appendicitis (RLQ), Diverticulitis (LLQ), Cholecystitis (RUQ), Pancreatitis (epigastric, radiating to back), PUD (epigastric), Renal Colic (flank).
• Syncope/Pre-syncope: Cardiac (arrhythmia, structural heart disease, valvular disease), vasovagal, orthostatic hypotension, neurological (TIA, seizure). Rule out structural cardiac disease and arrhythmias as first priority.
• Weakness/Fatigue: Widespread vs. focal. Acute vs. chronic. Common underlying causes: Anaemia, thyroid disease, electrolyte imbalances, heart failure, malignancy, depression.

Diagnosis (Gold Standard)

Diagnosis often begins with a thorough history and physical exam. Initial investigations typically include FBC, U&Es, LFTs, CRP, ESR, ECG, CXR, and urinalysis. Specific 'gold standards' vary:

• Acute Coronary Syndrome (ACS): Serial Troponins and dynamic ECG changes (ST elevation, depression, T wave inversion). Coronary angiography for definitive anatomical diagnosis and intervention.
• Pulmonary Embolism (PE): CT Pulmonary Angiogram (CTPA). V/Q scan if CTPA is contraindicated (e.g., renal impairment, contrast allergy). D-dimer is useful for ruling out PE in low probability patients.
• Heart Failure: Clinical diagnosis supported by Echocardiogram (evaluating EF, chamber size/function) and elevated Natriuretic Peptides (BNP/NT-proBNP).
• Pneumonia: Clinical features (cough, fever, dyspnea) combined with Chest X-ray (CXR) showing infiltrates. Sputum culture can identify the causative pathogen.
• Acute Kidney Injury (AKI): Defined by a rapid rise in serum creatinine (≥26.5 µmol/L within 48 hours OR ≥1.5x baseline within 7 days) AND/OR oliguria.
• Diabetes Mellitus: HbA1c ≥6.5%, Fasting Plasma Glucose ≥7.0 mmol/L, or 2-hour Plasma Glucose ≥11.1 mmol/L during an Oral Glucose Tolerance Test (OGTT).
• Deep Vein Thrombosis (DVT): Compression Ultrasonography is the primary diagnostic modality.

Management (First Line)

Initial management focuses on stabilisation and addressing the underlying cause.

• ABCs: Airway, Breathing, Circulation are paramount in all acute medical emergencies. Administer oxygen if SpO2 <94% or if indicated by clinical condition.
• Sepsis: Early recognition (using SIRS/SOFA/qSOFA criteria), implement 3-hour bundle (measure lactate, obtain blood cultures, administer broad-spectrum IV antibiotics, administer IV fluids for hypotension/lactate), and 6-hour bundle (vasopressors for ongoing hypotension, re-measure lactate).
• Acute Coronary Syndrome (ACS): MONA (Morphine, Oxygen, Nitroglycerin, Aspirin) + Clopidogrel/Ticagrelor. Reperfusion therapy (Percutaneous Coronary Intervention - PCI, or thrombolysis) is critical for STEMI.
• Asthma Exacerbation: Short-acting beta-agonists (SABA - e.g., salbutamol) & systemic corticosteroids (e.g., prednisolone). Oxygen, ipratropium, and magnesium sulfate for severe cases.
• COPD Exacerbation: SABA/SAMA (short-acting anticholinergic), systemic corticosteroids, and antibiotics if purulent sputum or signs of bacterial infection. Non-invasive ventilation (NIV) may be needed.
• Hypertensive Urgency/Emergency: Oral agents for urgency (no end-organ damage), IV agents for emergency (with end-organ damage, target controlled reduction).
• Fluid & Electrolyte Imbalance: Correct underlying cause, judicious fluid administration (e.g., Normal Saline, Hartmann's solution), and specific electrolyte replacement (e.g., Potassium, Sodium, Magnesium, Calcium).

Exam Red Flags