Master Medicine & Allied
for PMDC NLE Step 1
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Core Concepts
Focus on a systematic approach: ABCs (Airway, Breathing, Circulation), Vitals, History, Physical Exam. Key differentials for common symptoms (e.g., chest pain, dyspnea). Understand common risk factors: Hypertension, Diabetes, Dyslipidemia, Smoking, Obesity. Prioritize life-threatening conditions.
Clinical Presentation
- Acute Coronary Syndromes (ACS): Crushing substernal chest pain, radiation to left arm/jaw, dyspnea, diaphoresis, nausea. Atypical presentations common in women, elderly, diabetics.
- Heart Failure (Acute Decompensated): Progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND), bilateral pitting edema, crackles/rales, S3 gallop, elevated JVP.
- Atrial Fibrillation (AFib): Palpitations, irregular irregular pulse, fatigue, dyspnea, chest discomfort, or often asymptomatic.
- Asthma/COPD Exacerbation: Worsening dyspnea, wheezing, cough, chest tightness, increased sputum production/purulence.
- Pneumonia: Fever, productive cough, pleuritic chest pain, dyspnea, chills. Elderly may present with confusion or weakness.
- Pulmonary Embolism (PE): Sudden onset dyspnea, pleuritic chest pain, cough, hemoptysis, syncope. May have signs of DVT (leg swelling, pain).
- Peptic Ulcer Disease (PUD): Epigastric pain (burning, gnawing), often relieved by food (duodenal ulcer) or worsened by food (gastric ulcer). Nausea, bloating, melena/hematemesis if bleeding.
- Acute Pancreatitis: Severe, constant epigastric pain radiating to the back, nausea, vomiting. Relieved by leaning forward.
- Acute Kidney Injury (AKI): Oliguria/anuria, generalized weakness, altered mental status, edema, nausea. Symptoms often nonspecific.
- Diabetic Ketoacidosis (DKA): Polyuria, polydipsia, polyphagia, nausea, vomiting, abdominal pain, Kussmaul respirations (deep, rapid), fruity breath odor, altered mental status.
- Hypoglycemia: Tremors, palpitations, anxiety, sweating, hunger, confusion, dizziness, slurred speech, seizures, coma.
- Acute Ischemic Stroke: Sudden onset focal neurological deficit (unilateral weakness/numbness, aphasia, visual field defects, facial droop). Time is brain!
- Bacterial Meningitis: Fever, severe headache, nuchal rigidity (stiff neck), photophobia, altered mental status. Kernig's/Brudzinski's signs may be positive.
- Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection. Fever/hypothermia, tachycardia, hypotension, tachypnea, altered mental status, elevated lactate.
Diagnosis (Gold Standard / Key Initial Test)
ACS: ECG (STEMI), Cardiac Troponins (NSTEMI/UA). Heart Failure: Echocardiogram (EF, chamber size/function), BNP/NT-proBNP. AFib: ECG. Pneumonia: Chest X-ray. PE: CT Pulmonary Angiogram (CTPA). V/Q scan if renal dysfunction or contrast allergy. Cirrhosis: Liver biopsy (definitive), but clinical/radiological findings often suffice. Acute Pancreatitis: Serum Lipase/Amylase (>3x upper limit of normal). AKI: Serum Creatinine elevation (absolute or relative to baseline). DKA: Glucose >250 mg/dL, pH <7.3, Bicarbonate <18 mEq/L, Ketones in urine/serum. Acute Ischemic Stroke: Non-contrast CT Head (to rule out hemorrhage before thrombolysis). Bacterial Meningitis: Lumbar Puncture (CSF analysis: high protein, low glucose, high WBCs, Gram stain). Sepsis: Blood cultures, serum lactate.
Management (First Line)
ACS: MONA (Morphine, Oxygen, Nitrates, Aspirin), P2Y12 inhibitor, reperfusion (PCI or Fibrinolysis). Heart Failure (Acute Decompensated): IV Diuretics (Furosemide), Oxygen, Vasodilators (Nitroglycerin). AFib (Rate Control): Beta-blockers (e.g., Metoprolol) or Calcium Channel Blockers (e.g., Diltiazem). (Rhythm control: Cardioversion, antiarrhythmics). Pneumonia: Empiric antibiotics (e.g., Macrolide or Doxycycline for outpatient, Beta-lactam + Macrolide/Fluoroquinolone for inpatient). PE: Anticoagulation (LMWH, Fondaparinux, or UFH). Thrombolysis for massive PE with hemodynamic instability. Acute Pancreatitis: Aggressive IV fluids, NPO (bowel rest), pain control (opioids). Hyperkalemia: IV Calcium Gluconate (cardiac stabilization), IV Insulin + Glucose, Salbutamol, Loop diuretics, Sodium Polystyrene Sulfonate (Kayexalate). DKA: IV fluids (Normal Saline), IV regular insulin drip, Potassium replacement. Hypoglycemia: Oral glucose (conscious), IV Dextrose (unconscious). Acute Ischemic Stroke: IV tPA (Alteplase) within 4.5 hours of symptom onset (if no contraindications); Mechanical thrombectomy for large vessel occlusion (up to 24 hours). Bacterial Meningitis: Empiric IV antibiotics (e.g., Ceftriaxone + Vancomycin), Dexamethasone. Sepsis: "Hour-1 Bundle" - IV fluids (30mL/kg crystalloid), broad-spectrum antibiotics (after cultures), vasopressors for hypotension.
Exam Red Flags
- Chest pain + Hypotension/Bradycardia: Inferior MI (RCA involvement), consider RV infarct.
- Sudden, severe "tearing" chest or back pain, wide pulse pressure, difference in BP between arms: Aortic Dissection.
- New neurological deficit in an anticoagulated patient: Intracranial Hemorrhage until proven otherwise – CT Head STAT.
- Unconscious patient with diabetes: ALWAYS treat for hypoglycemia first (IV Dextrose) if blood glucose unknown.
- Acute abdominal pain with rigid abdomen: Perforation of a hollow viscus. Surgical emergency.
- Pulmonary Embolism with hemodynamic instability (hypotension): Consider thrombolysis or embolectomy.
- Status Epilepticus (seizure >5 minutes or recurrent without recovery): Treat immediately with benzodiazepines (e.g., Lorazepam, Midazolam).
- Any infection with signs of organ dysfunction (e.g., AKI, hypotension, altered mental status): Sepsis, manage aggressively.
- Fever + Headache + Neck Stiffness: Meningitis – empiric antibiotics and consider LP.
Sample Practice Questions
A 22-year-old female with a known history of asthma presents to the emergency department with acute onset severe shortness of breath, wheezing, and cough. She is afebrile, alert, and oriented. On examination, she is tachypneic (RR 28/min), tachycardic (HR 110/min), and has widespread expiratory polyphonic wheezes bilaterally. Her oxygen saturation is 90% on room air.
A 19-year-old female, known to have Type 1 Diabetes Mellitus, presents to the emergency department with a 2-day history of increasing polyuria, polydipsia, generalized weakness, and abdominal pain. Her parents report she has been less compliant with her insulin injections recently. On examination, she is lethargic but arousable. Her breathing is deep and rapid (Kussmaul respiration), and her breath has a fruity odor. Blood pressure is 90/60 mmHg, and heart rate is 115 bpm.
A 55-year-old male presents to the emergency department with sudden onset severe retrosternal chest pain radiating to his left arm, associated with sweating and shortness of breath for 1 hour. He has a history of hypertension and dyslipidemia. On examination, his pulse is 98 bpm, BP 140/90 mmHg, respiratory rate 22/min. ECG shows ST-segment elevation in leads V2-V5.
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