Master Medicine & Allied
for PMDC NLE Step 1

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.

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