Pdf provides different kuhs medicine essays and the answers

1. KUHS ESSAYS DISCUSSIONS
ONLINE LIVE CLASS
Dr Rahul Rajeev MBBS MD DM
Medicine Faculty

2. • A 55 year old man, who is a chronic smoker presented with sudden onset
breathlessness and cough with pink frothy sputum since one day. He also
has associated few episodes of breathlessness during night times.
On examination, tachypnea, tachycardia and hypertension noted.
SPO2 is 90% and LVS3 is heard on auscultation.
a) What is the probable diagnosis ? (2)
b) What are the causes of this condition ? (3)
c) Investigations required ? (2)
d) Treatment of this condition ? (3)

3. Probable diagnosis
•Acute Pulmonary Edema
Acute Decompensated LV (Heart) Failure
Systemic Hypertension

4. Causes of Acute Cardiogenic Pulmonary Edema
• Acute Coronary Syndrome
• Uncontrolled Hypertension
• Arrhythmias : Tachyarrhythmias & Bradyarrhythmias
• Decompensated Valvular heart disease
• Acute on Chronic Kidney Disease
• Severe anemia
• Drugs : Beta blockers, Non DHP CCB
• Vigorous fluid administration
• Thyrotoxicosis
• Systemic Infections

5. Investigations Required
• ECG
• Blood investigations
Routines : Hb, TC, Electrolytes, LFT,RFT
NT-Pro BNP, hs Trop T or I
Thyroid Function Test
• Chest X-ray
• Echocardiography

6. Treatment of Acute Cardiogenic Pulmonary Edema
• Propped up position
• O2 inhalation (SpO2 < 90%)
- Mask
- Nasal prongs
- NIV
- Intubation

7. Nasal prongs

8. Hudson’s oxygen mask
• FiO2 60%

9. Non-rebreathing mask (NRBM)
• Face mask is connected to a reservoir bag that has high concentration of
oxygen
• One way valve between mask and reservoir bag
• One-way valves prevent exhaled air from re-entering the oxygen reservoir.
• Flow rate : 10 litres/min
• FiO2 : 80-95 %

10. Non Invasive Ventilation (NIV)
• FiO2 100 %

11. • Secure iv line (blood for investigation )
• Diuretic therapy : IV loop diuretic
• Early vasodilator therapy : Severe Hypertension, Acute MR, Acute AR
Nitroprusside, Nitroglycerine
• Severe ADHF in cardiogenic shock : Inotrope

12. • 30 year old female presents with an episode of tonic clonic convulsions.
She recently delivered a pre-term underweight baby. The patient’s
mother noticed a rigid posture, urinary incontinence and tongue bite.
On examination, she is drowsy, arousable and complaints of headache.
Her blood pressure is 110/70 mmHg. Answer the following.
a) What is your probable diagnosis ? (2)
b) What are the differential diagnosis ? (3)
c) How will you confirm the diagnosis ? (2)
d) How will you treat the patient ? (3)

13. Probable diagnosis
•Post Partum Seizures
Cerebral venous sinus thrombosis

14. Differential Diagnosis
• Post partum eclampsia
• Posterior Reversible Encephalopathy Syndrome
• Reversible Cerebral Vasoconstriction Syndrome
• Post-dural puncture seizure
• Sub-arachnoid hemorrhage

15. Confirming the Diagnosis
•MRI Brain + MRV + MRA
•MRI Brain + TOF (MRV + MRA)

16. Treatment
•Oxygen supplementation
•IV Fluids
•IV Antiepileptic
•IV Mannitol
•Anticoagulation : 3-6 months. Target INR 2-3

17. • 55 year old female who is a known case of Mitral Stenosis and also with a
history of type 2 Diabetes Mellitus & Systemic Hypertension presented
with sudden onset weakness of right side of the body of 2 hours duration.
There was deviation of angle of mouth to the left side with normal forehead wrinkling.
Pulse rate : 150/minute, irregularly irregular. BP : 160/98 mmHg.
a) What is your probable diagnosis ?
b) What investigations you will do in the emergency department ?
c) How will you manage this patient ?
d) How will you prevent further episodes ?

18. Probable diagnosis
• Acute onset Right Hemiplegia + Right UMN facial palsy
Left internal capsule lesion
Acute Stroke in Left MCA territory possibly embolic in origin
Mitral Stenosis with Atrial Fibrillation
Type 2 Diabetes Mellitus
Systemic Hypertension

19. Investigations
•ECG
•RBS
•PT-INR
• CT Brain + CT angiography (if required)

20. Ischemic stroke Hemorrhagic stroke
• IV thrombolysis
• If there is LVO
IV thrombolysis
followed by Mechanical thrombectomy
• Target Systolic BP < 140 mm Hg
• IV Mannitol
• Antiepileptic (if required)
• Antidote (if required)
FFP, PCC, Vitamin K

21. Preventing Further Episodes
• Anticoagulant – Warfarin
• Rate control strategies
• Antihypertensive
• Blood sugar control
• Statin

22. A 50 year old male presented with progressive breathlessness and swelling of both feet of 2 years
duration. Currently he is comfortable at rest, but develops breathlessness on climbing stairs or walking
about 50 meters. On examination, Pulse rate 110/ minute and BP 130/90 mm Hg, Respiratory rate
is 22/minute . JVP was 12 cm H20. On auscultation, LVS3 present and bilateral fine crepitations
were present over the lung bases. Liver was palpable 3 cm below right costal margin in
midclavicular line. There is no free fluid in the abdomen. He has a history of STEMI 1 year back and is on
medical treatment. He is also on statin treatment for high cholesterol.
a) What is your probable diagnosis ? (2)
b) What other causes can cause this condition ? (3)
c) How will you confirm the diagnosis ? (2)
d) How will you treat the condition ? (3)

23. What is the probable diagnosis ?
• Chronic Biventricular Heart Failure
NYHA Grade II
ACC-AHA Stage C
K/C/O Coronary Artery Disease - Acute Coronary Syndrome - STEMI
Systemic Hypertension
Dyslipidemia
• Congestive Heart Failure – Old term

24. What are the causes of this condition ?
• Coronary artery disease
• Hypertension
• Regurgitant valvular lesions
• Obstructive valvular lesions
• Arrhythmias
• Cor-Pulmonale
• Cardiomyopathies
- Genetic (DCM, HCM, RCM)
- Toxin (Alcohol)
• Myocarditis
• Pericarditis with effusion
• Collagen vascular disease -
- SLE
• Endocrine conditions
- Diabetes
- Hyper and Hypothyroidism
- Pheochromocytoma
• Obstructive sleep apnea
• Fluid overload
- Anemia
- Chronic Kidney Disease

25. How will you confirm the diagnosis ?
•Basic Lab Investigations
CBC
Serum electrolytes
HbA1C
LFT
RFT
TFT
Urine Routine
•Cardiac evaluation
ECG
Chest X-ray
NT-Pro BNP
Troponin I/T
Echo
Holter monitoring
MRI
Cardiac CT angio
Nuclear imaging : SPECT & PET
Right heart catheterization

26. How will you treat the condition ?
• General measures
• Pharmacologic therapies
• Cardiac Resynchronization Therapy
• Mechanical Circulatory Support Devices
• Cardiac Transplantation

27. General Measures
•Dietary sodium restriction
Mild – Moderate heart failure : 2-3 gram/day
Advanced heart failure : < 2 gram/day
•Fluid restriction
•Treatment of underlying conditions & co-morbidities

28. Pharmacologic therapies
• ARNI
(Angiotensin Receptor Neprilysin
Inhibitor)
Sacubitril + Valsartan
• ACEI/ARB
• Beta blocker
• Loop diuretic
• Aldosterone antagonist
• Hydralazine
• SGLT2 inhibitor
• Isosorbide dinitrate
• Ivabradine
• Initial therapy
ARNI/ACEI/ARB
+
Diuretic
+
Beta blocker

29. Cardiac Resynchronization Therapy
•For selected patients with HFrEF
•Simultaneous pacing of LV & RV
•By placing electrodes into LV & RV
•Restore mechanical synchrony
by electrically activating the heart in a synchronized manner

30. Mechanical Circulatory Support Devices
•Ventricular Assist Devices
•Intra-aortic balloon pump
•ECMO

31. • 45 year old female complaints of diplopia, slurring of speech towards
the end of the day for the last 1-2 months duration. Last few days, she
feels difficulty in breathing. She gives a history of intake of Azithromycin for URTI.
On examination, ptosis is present. Her reflexes, sensations & power of limbs
normal.
a) What is the diagnosis ? (2)
b) Pathophysiology of the condition ? (3)
c) Drugs precipitating the condition ? (2)
d) Treatment (3)

32. Diagnosis
• Progressive fluctuating Extra-ocular muscle weakness
LMN Dysarthria
Bulbar palsy
Neuromuscular junction disorder
Myasthenia Gravis – worsened with Azithromycin intake
Recent Upper Respiratory Tract Infection

33. Pathophysiology
• Post synaptic Neuromuscular Junction Disorder
• Autoimmune. Antibodies against Acetyl Choline Receptor
MuSK, LRP4,Agrin
• Decreased amplitude of EPP. Reduced production of AP
• Type 2 Hypersensitivity
• Other associations
Thymic hyperplasia, Thymoma

35. Drugs precipitating this condition
• Other drugs
- Penicillamine
- Beta blocker (Propranolol)
- Chloroquine
- Quinidine
- Botulinum toxin

36. TREATMENT
• Acetyl cholinesterase inhibitors
- Pyridostigmine
- Tilstigmine
• Steroids
• Steroid sparing agents - Azathioprine, MMF
• Eculizumab
• Myasthenic crisis
- IvIg
- Plasma exchange

37. • A 70 year old male having hyperlipidemia presents with inability to move his left hand
and left leg of one day duration. He felt that his left hand is weak in the morning and
in the evening developed weakness of left leg. On examination, vital signs were
stable. Spasticity was noted in left upper and lower limb. Grade 4 power on left side of the body.
Left plantar extensor. Deep Tendon Reflexes were exaggerated on left side.
Other systems were within normal limits.
a) What is your probable diagnosis ? (2)
b) Where is the lesion ? (2)
c) How will you confirm the diagnosis ? (3)
d) How will you treat this condition ? (3)

38. Diagnosis
• Acute onset Left Spastic Hemiparesis
Right corona radiata lesion
Acute Ischemic Stroke in Right Middle Cerebral Artery probably thrombotic
Dyslipidemia

39. Where is the lesion ?
•Right Subcortical region (Corona radiata)

40. How will you confirm the diagnosis ?
• MRI Brain + MR angiography
OR
CT Brain + CT angiography
• Carotid artery doppler
• Transcranial doppler
• Blood routines & viral markers
• HbA1c, FBS, PPBS, FLP
• ECG
• Troponin I/T
• Echo
• Holter monitoring

41. How will you treat this condition ?
• Loading dose of aspirin 300 mg followed by 150 mg daily
• Atorvastatin 40 mg HS
• Anticoagulant (only if evaluation shows any evidence of cardioembolic stroke)
• Optimal control of Blood Pressure, Diabetes
• Avoiding risk factors : Smoking, alcoholism
• Physiotherapy

42. • 19 year female patient presents with puffiness of the face with pedal
edema since 15 days. She noticed frothy urine and decreased urine
output. On examination, blood pressure is 150/100 Hg.
a) What is the probable diagnosis ? (2)
b) How will you confirm this disease ? (3)
c) Discuss the management of this condition ? (3)
d) What are the complications of this condition ? (2)

43. PROBABLE DIAGNOSIS
Acute onset Nephritic syndrome
Post-streptococcal glomerulonephritis

45. CONFIRMING DIAGNOSIS
• Urine routine : RBC Casts & Dysmorphic RBC’s
• Sub-nephrotic range proteinuria
• Reduced GFR
• Decreased level of C3, Normal level of C4
• anti DNA’se, anti hyaluronidase, increased ASO titre
• Throat culture
• Renal biopsy (rarely required)
Light microscopy, Immunofluorescence microscopy, Electron microscopy

46. LIGHT MICROSCOPY
Large glomeruli, Increased cellularity

47. IMMUNOFLUORESCENCE MICROSCOPY

48. ELECTRON MICROSCOPY
Subepithelial electron dense deposits

49. MANAGEMENT
• Fluid restriction (Intake = Output + 500 ml)
• Sodium restriction
• Loop diuretic (if there are features of fluid overload)
• Close monitoring of Blood Pressure
• Preferred oral antihypertensive : Calcium channel blocker
• IV anti-Hypertensive (in hypertensive crisis)
• Treat electrolyte imbalances (if any)
• Dialysis

50. COMPLICATIONS
• Acute Kidney Injury
• Rapidly Progressive Glomerulonephritis (RPGN)
• Nephrotic proteinuria
• ESRD (rare)
• Hypertensive crisis
• Acute Left Ventricular failure
• Biventricular Failure (Congestive Cardiac Failure)
• Death

51. • 32 year old female presented with breathlessness on exertion for 6 months
duration, which worsened over last 2 weeks. For past 3 days, she is
also having pink frothy sputum. She has a past history of rheumatic fever at
15 years of age and not on antibiotic prophylaxis. On examination, pulse
rate is 114/min, irregularly irregular. BP 114/80 mm Hg. Auscultation
showed diastolic low pitched rumbling mid-diastolic murmur at apex.
Bilateral basal crepitations were heard over the lung base.
a) What is the complete diagnosis ? (2)
b) Discuss the etiopathogenesis ? (2)
c) What are the investigations to be done ? (3)
d) How will you treat this patient ? (3)

52. DIAGNOSIS
• Acute Cardiogenic Pulmonary Edema
Acquired valvular heart disease
Decompensated Chronic Mitral Stenosis
Rheumatic in origin (Rheumatic Heart Disease)
Atrial Fibrillation
No signs of Pulmonary Arterial Hypertension
No signs of Infective endocarditis

53. ETIOPATHOGENESIS
• Etiology
- Rheumatic fever
- Congenital mitral stenosis
- Mitral annular calcification
- Left atrial myxoma
- Cortriatriatum
• Pathology
- Inflamed and edematous valve leaflets
- Fusion of commissures
- Chordae tendinae shortening & fusion

54. INVESTIGATIONS
• ECG
Atrial Fibrillation , P mitrale
• Echocardiography
TEE preferred
Transvalvular pressure gradient
Chamber dimensions
Valve architecture
Vegetations
• Blood culture
• TFT
• Chest X-ray
Left atrial enlargement
- Straightening of left heart border
- Double density sign
- Splaying of carina
- Elevation of left main bronchus
Prominence of main pulmonary artery
Dilation of upper lobe pulmonary veins
Pulmonary edema (Kerley lines, Batwing opacities)

55. INVESTIGATIONS
• Basic Blood Investigations
CBC, ESR
LFT, RFT
Serum electrolytes
HIV, HBsAg, anti HCV

57. TREATMENT
• Management of acute pulmonary edema
• Management of atrial fibrillation
• Prevention of recurrent rheumatic fever
• Mitral valve repair/replacement

58. TREATMENT
• Management of acute pulmonary edema
(discussed in 1st question of my class)
• Management of atrial fibrillation : Warfarin
• Prevention of recurrent rheumatic fever : Penicillin prophylaxis
• Mitral valvotomy : Percutaneous mitral balloon valvotomy

59. AHA GUIDELINE

60. WHO GUIDELINE

62. • 25 year old female presented with fever, oral ulcers and polyarthralgia
of 2 months duration. She also gave history of 2 abortions.
a) What is the likely diagnosis ? (1)
b) How will you investigate the patient ? (2)
c) How will you treat ? (3)
d) What advice will you give regarding future pregnancy ? (4)

63. DIAGNOSIS
• Subacute onset of
- Constitutional
- Mucocutaneous
- Musculoskeletal manifestations
• Recurrent pregnancy loss
• Systemic Lupus Erythematosus
• Secondary APLA syndrome

64. INVESTIGATION
• CBC, ESR
• LFT, RFT
• Serum electrolytes
• Serum CRP
• Urine routine
• Chest X-ray
• HIV, HBsAg, anti HCV
• ANA
• ANA Profile
• PT, aPTT
• Anti-phospholipid antibodies
- Anticardiolipin antibody
- Anti beta2 glycoprotein antibody
- Lupus anticoagulant
• RA factor
• anti CCP antibody
• Blood Culture
• Echocardiography
• Pathergy test

65. TREATMENT
• Oral steroid (Prednisolone)
• Steroid sparing agents : Azathioprine, MMF
• Hydroxychloroquine
• If not responding to above treatment, consider monoclonal antibodies
- Rituximab
- Anifrolumab
- Belimumab
• Lifelong Anticoagulation

66. FUTURE PREGNANCY
• LMWH throughout pregnancy + Low dose aspirin
• Post-partum lifelong anticoagulation
• HCQ may be continued during pregnancy in required
• Prednisolone in the lowest possible dose for shortest period
• Azathioprine – if disease activity demands
• Presence of anti Ro – vigilant fetal heart rate monitoring
• Breastfeeding – Can be continued, except if taking high dose immunosuppressants

67. • A 20 year old male travels in a two wheeler in a dusty atmosphere
and develops sneezing and breathlessness. He gives past episodes of
wheezing. Auscultation of chest showed bilateral polyphonic wheezes
a) What is your diagnosis ? (2)
b) How will you investigate him ? (3)
c) How will you manage ? (3)
d) Precautions to prevent further episodes ? (2)

68. DIAGNOSIS
•Reversible airway hyper-responsiveness
Obstructive Lung Disease
Bronchial asthma

69. INVESTIGATIONS
• Basic investigations
CBC, ESR
LFT, RFT
Serum electrolytes
HIV, HBsAg, anti HCV
• Targeted investigations
Spirometry
Peak expiratory flow
Chest X-ray
Allergy tests

70. Establishing diagnosis of Bronchial Asthma
•Expiratory airflow limitation
•Variability in airflow limitation
•Reversibility in airflow limitation

71. Expiratory airflow limitation
•Spirometer
- Forced Expiratory Volume in 1 sec (FEV1)
•Peak Expiratory Flow meter
- Peak Expiratory Flow

72. Spirometry
•Reduced FEV1
•Reduced FEV1/FVC (less than lower limit of normal)
LLN – (>0.75 in adults)

73. Variability airflow limitation
• Diurnal variability >10% for adults is regarded as excessive

74. Reversibility in airflow limitation
• Rapid improvement in FEV1 or PEF
minutes after inhalation of a rapid-acting bronchodilator
such as 200–400 mcg salbutamol
• More sustained improvement over days or weeks after the
introduction of effective controller treatment such as ICS
• Increase in FEV1 of >12% and >200 mL from baseline, or
(if spirometry is not available) a change in PEF of at least 20%.

77. Allergic tests
•Skin prick test
•Serum IgE

78. MANAGEMENT

83. GINA GUIDELINE – STEPWISE MANAGEMENT

84. PRECAUTIONS TO PREVENT FURTHER EPISODES
• Good drug compliance
• Avoidance of outdoor allergens
• Avoidance of indoor allergens
• Avoidance of outdoor air pollution
• Avoidance of indoor air pollution
• Quit smoking
• Regular physical activity
• Avoidance of occupational exposures
• Avoid medications that worsen asthma
• Weight reduction
• Breathing exercises
• Avoid food allergans

85. MANAGEMENT OF ASTHMA EXACERBATIONS

86. Initial assessment
•A,B,C
Airway, Breathing, Circulation
•Are there any of the following ?
- Drowsiness, Confusion, Silent chest
ICU

87. SEVERE MILD - MODERATE
• Talks in words
• Sits hunched forwards
• Agitated
• Respiratory rate > 30/min
• Accessory muscles of respiration used
• Pulse rate > 120/min
• O2 saturation < 90%
• PEF < 50 % of predicted
• Talks in phrases
• Prefers sitting to lying
• Not agitated
• Respiratory rate increased
• Accessory muscles not used
• Pulse rate 100-120/min
• O2 saturation 90-95%
• PEF > 50 % of predicted

88. MAIN THERAPIES
• Repetitive administration of SABA
• Systemic corticosteroids
• Oxygen administration
• Antibiotics (only if there is an infection as trigger)

89. SEVERE MILD - MODERATE
• Oxygen
• SABA : Salbutamol
• Parenteral steroid : Hydrocortisone
• Ipratropium bromide
• IV Magnesium (if not responding)
• Oxygen
• SABA : Salbutamol
• Oral steroid : Prednisolone

90. SEVERE MILD - MODERATE
• Oxygen
• SABA : Salbutamol
4-10 puff via MDI
Repeat every 20 min for 1 hour
• Parenteral steroid : Hydrocortisone
100 mg iv stat followed by Q8H
• Ipratropium bromide
• IV Magnesium (if not responding)
• Oxygen
• SABA : Salbutamol
4-10 puff via MDI
Repeat every 20 min for 1 hour
• Oral steroid : Prednisolone
1mg/kg prednisolone : 50 mg

91. AT DISCHARGE
• Suggest Controller therapy
• Suggest Reliever therapy
• Proper MDI technique to be taught
• Continue Prednisolone for 1 week
• Follow up after 1 week

92. • An elderly male presents with swelling of his right lower limb after a
long flight journey. He was brought to the emergency department
with sudden onset breathlessness. Answer the following ?
a) What is the most probable diagnosis ? (2)
b) Discuss the risk factors & clinical features ? (3)
c) How will you investigate the patient ? (3)
d) Discuss the treatment ? (2)

93. DIAGNOSIS
•Acute onset breathlessness
Pulmonary embolism
Deep venous thrombosis of Right lower limb
Precipitated by immobilization

94. RISK FACTORS

95. CLINICAL FEATURES
Symptoms
•Dyspnea
•Chest pain
•Hemoptysis
Signs
•Tachycardia
•Hypotension
•JVP elevated
•Pedal edema
•Wide split of S2

96. INVESTIGATIONS
• Blood routines
CBC, ESR
LFT, RFT
Serum electrolytes
HIV, HBsAg, anti HCV
PT-INR, aPTT
• Targeted investigations
D- dimer : screening test
ECG : Sinus tachycardia, S1Q3T3
Chest X-ray
CTPA : I.O.C
Filling defects in pulmonary circulation
V/Q scan : Perfusion defects
Echo : RV hypokinesia

98. TREATMENT
• Oxygen inhalation
• Severe hypoxemia – Mechanical ventilation
• Cautious administration of IV fluid (Normal saline)
• Hemodynamically stable - Anticoagulation (Initially Heparin followed by OAC)
• Hemodynamically unstable – Thrombolysis (if no contraindication) + Inotropes
• If contraindication to thrombolysis – Catheter or surgical embolectomy
• Recurrent pulmonary embolism despite anticoagulation – IVC filter

99. • A 60 year old male who is a chronic alcoholic & smoker, with history
of systemic hypertension and type 2 diabetes mellitus, now presented with
acute onset central chest pain & sweating for the past 1 hour. His Pulse rate is
100/minute and Blood pressure is 130/80 mm Hg. ECG showed ST depression
with T inversions in lead V3-V6.
a) What is the probable diagnosis ? (2)
b) How will you confirm the diagnosis ? (2)
c) What is the immediate management ? (4)
d) How will you prevent recurrence ? (2)

100. DIAGNOSIS
• Acute onset Anginal chest pain
Ischemic Heart Disease
Non ST Elevation - Acute Coronary Syndrome
Type 2 Diabetes Mellitus
Systemic Hypertension
Chronic smoker
Chronic alcoholic

101. CONFIRMING DIAGNOSIS
• ECG & Cardiac biomarkers – cornerstones of making diagnosis
• ECG
ST segment depression
T wave inversion
Normal ECG does not completely rule out ACS

104. •Cardiac biomarkers
Cardiac Troponin (Trop I/Trop T) : within 4 hours
High sensitivity Troponin I (hs Trop I) – most specific
High sensitivity Troponin T (hs Trop T)
CK-MB : within 4 hours
Heart Fatty acid binding protein : 30 minutes
Myoglobin : 2 hours
LDH : Normal - LDH2 > LDH1. MI – LDH1 > LDH2
Copeptin : Recent biomarker

105. •Echocardiography
Regional Wall Motion Abnormalities (RWMA)
Left Ventricular Ejection Fraction (EF)
Mechanical complications : Mitral Regurgitation, Ventricular Septal Rupture
Rule out other differential diagnosis
(Aortic Dissection, Pulmonary embolism, Aortic Stenosis,
Hypertrophic cardiomyopathy, Pericardial effusion)

106. Other Investigations
•Blood routines
•Chest X-ray
•Fasting Lipid Profile
•FBS, PPBS
•HbA1c
•C-reactive protein
•NT-pro BNP
•Repeat ECG (if required)

107. TREATMENT
• Immediate general measures
• Pain relief
• Risk stratification : GRACE, TIMI
• Choice of management strategy : Early invasive versus Conservative
• Initiation of antithrombotic therapy : Antiplatelet & Anticoagulant

108. Immediate general measures
• Admission preferably in ICU
• Continuous ECG monitoring
• Secure iv access
• No ambulation
(until patient is stable and free of chest discomfort for 12-24 hours)
• O2 supplementation : if saturation is less than 90 percent

109. Pain Relief (Anti-ischemic therapy)
• Sublingual NTG (0.4 mg every 5 minutes for 3 doses)
Isosorbide dinitrate
Isosorbide mononitrate
• NTG iv infusion : persistent pain, hypertension, heart failure
(watchout for hypotension)
• Oral Beta blocker : Metoprolol
• IV morphine sulfate : (persistent severe chest pain despite nitrates & beta blocker)
• Oral calcium channel blocker

110. •Other anti-anginal drugs
- Nicorandil
- Ivabradine
- Ranolazine

111. Choice of management strategy
• Early invasive versus Conservative
Early invasive : Revascularization
Identify location & extent of lesion via coronary angiography
Opening up the culprit vessel : PCI or CABG

116. Immediate invasive strategy < 2 hours
• Hemodynamic instability
• Cardiogenic shock
• Recurrent/Refractory chest pain despite medical treatment
• Life threatening arrhythmias
• Mechanical complications of MI
• Acute Cardiogenic Pulmonary Edema due to MI

117. Early invasive strategy < 24 hours
•Positive cardiac troponins
•Dynamic ST-T changes
•High GRACE/TIMI risk score

118. Antithrombotic Therapy
•Antiplatelet therapy
•Anticoagulation

119. Antiplatelet Therapy
• Loading dose of dual antiplatelets
Aspirin + a P2Y12 receptor blocker
Aspirin 300 mg
Clopidogrel 300 - 600 mg
Ticagrelor 180 mg
Prasugrel 60 mg
• Loading dose of statin
Atorvastatin 80 mg

120. • GpIIb/IIIa inhibitor : Abciximab, Eptifibatide, Tirofiban
Added in patients selected for early invasive strategy

121. Anticoagulation
•Unfractionated Heparin
•Enoxaparin
•Fondaparinux
•Bivalirudin

122. • Unfractionated Heparin
As per guideline : 5000 Units iv stat f/b 1000 U/hour infusion for 48 hours
Resource limited settings : 5000 Units iv stat f/b 5000 U 6th hourly
Monitor aPTT during treatment

123. PREVENTING RECURRENCE
• Dual antiplatelet for at-least 1 year followed by aspirin lifelong
Aspirin 75 mg once daily
Clopidogrel 75 mg once daily
Ticagrelor 90 mg twice daily
Prasugrel 10 mg once daily
• Atorvastatin 40 mg daily. Target LDL < 70 mg%

124. PREVENTING RECURRENCE
• Beta blocker
• Anti-anginal therapy
• ACE I/ARB
• Optimal management of Diabetes & Hypertension
• Quit smoking, alcoholism
• Healthy diet

125. • A 50 year old male who is a chronic smoker and with a history of systemic
hypertension and type 2 diabetes mellitus, now presented with acute onset
central chest pain , radiating to the left arm & sweating for the past 2 hours.
His Pulse rate is 110/minute and Blood pressure is 126/80 mm Hg.
ECG showed ST elevation in lead I, aVL, V3, V4, V5 and V6.
a) What is the probable diagnosis ? (2)
b) What are the possible complications ? (2)
c) What is the immediate management ? (4)
d) How will you prevent recurrence ? (2)

131. ECG Leads
• V1, V2 : Septal Leads
• V3,V4 : Anterior Leads
• V5, V6 : Lateral Leads
• I, aVL : Lateral Leads
• II, III, aVF : Inferior Leads

134. V3R, V4R – RVMI V7,V8,V9 - PWMI

135. DIAGNOSIS
• Acute onset Anginal chest pain
Ischemic Heart Disease
Acute Coronary Syndrome
Anterolateral wall ST Elevation Myocardial Infarction
Type 2 Diabetes Mellitus
Systemic Hypertension
Chronic smoker

136. COMPLICATIONS OF MYOCARDIAL INFARCTION
•Arrhythmia
•Heart failure
•Cardiogenic shock
•Sudden death
•Re-infarction
•Mitral Regurgitation
•Ventricular Septal Defect
•Embolism
•Cardiac rupture
•Pericarditis
•Dressler’s syndrome
•Left ventricular aneurysm

137. TREATMENT OF STEMI
• Immediate general measures
• Pain relief
• Revascularization modalities
• Initiation of antithrombotic therapy : Antiplatelet & Anticoagulant

138. Immediate general measures
• Admission preferably in ICU
• Continuous ECG monitoring
• Secure iv access
• No ambulation
(until patient is stable and free of chest discomfort for 12-24 hours)
• O2 supplementation : if saturation is less than 90 percent

139. Pain Relief (Anti-ischemic therapy)
• Sublingual NTG (0.4 mg every 5 minutes for 3 doses)
Isosorbide dinitrate
Isosorbide mononitrate
• NTG iv infusion : persistent pain, hypertension, heart failure
(watchout for hypotension)
• Oral Beta blocker : Metoprolol
• IV morphine sulfate : (persistent severe chest pain despite nitrates & beta blocker)
• Oral calcium channel blocker

140. •Other anti-anginal drugs
- Nicorandil
- Ivabradine
- Ranolazine

141. Ithu vare valare sheriyanu ….

142. PCI IVThrombolysis

143. LAD Occlusion : Pre and Post PCI

144. REVASCULARIZATION
•Early phase of STEMI (0-12 hours) : PCI > Fibrinolysis
•Evolved STEMI (12-48 hours) : PCI
•Recent STEMI (>48 hours) : PCI (only if patient symptomatic)

145. Fibrinolytics (rtPA)
• Streptokinase : 1.5 million units over 60 minutes
• Alteplase : 15 mg iv bolus
0.75 mg/kg iv over 30 minutes
0.5 mg/kg iv over 60 minutes
• Tenecteplase
• Reteplase

146. FAILED THROMBOLYSIS ---> Emergency PCI
•< 50 % ST segment resolution at 1 hour
•Heart failure
•Hemodynamic or electrical instability
•Worsening ischemia

147. SUCCESSFUL THROMBOLYSIS – Routine PCI
• Coronary angiography (and PCI if required 2-24 hours after thrombolysis)

148. Antithrombotic Therapy
•Antiplatelet therapy
•Anticoagulation

149. Antiplatelet Therapy
• Loading dose of dual antiplatelets
Aspirin + a P2Y12 receptor blocker
Aspirin 300 mg
Clopidogrel 600 mg
Ticagrelor 180 mg
Prasugrel 60 mg
• Loading dose of statin
Atorvastatin 80 mg

150. Anticoagulation
•Unfractionated Heparin
•Enoxaparin
•Fondaparinux
•Bivalurudin

151. • Unfractionated Heparin
As per guideline : 5000 Units iv stat f/b 1000 U/hour infusion for 48 hours
Resource limited settings : 5000 Units iv stat f/b 5000 U 6th hourly
Monitor aPTT during treatment : Target 1.5-2 times of control

152. PREVENTING RECURRENCE
• Dual antiplatelet for at-least 1 year followed by aspirin lifelong
Aspirin 75 mg once daily
Clopidogrel 75 mg once daily
Ticagrelor 90 mg twice daily
Prasugrel 10 mg once daily
• Atorvastatin 40 mg daily. Target LDL < 70 mg%

153. PREVENTING RECURRENCE
• Beta blocker
• Anti-anginal therapy
• ACE I/ARB
• Optimal management of Diabetes & Hypertension
• Quit smoking, alcoholism
• Healthy diet

154. • A 46 year old female presented with sudden occurrence
of severe headache of her life associated with vomiting & giddiness.
a) List three probable diagnosis (2)
b) What would be the clinical features to support
any one of your listed diagnosis ? (2)
c) Outline the investigations required in this condition ? (3)
d) Outline the management of this patient ? (3)

155. DIAGNOSIS
• Thunderclap headache. Differential diagnosis are :
- Subarachnoid hemorrhage
- Intracerebral hemorrhage
- Cerebral venous sinus thrombosis
- Pituitary apoplexy
- Acute Subdural hemorrhage
- Reversible Cerebral Vasoconstriction Syndrome (RCVS)

156. Subarachnoid hemorrhage
• Symptoms
- Thunderclap headache
- Neck pain
- Nausea, vomiting
- Seizures
- Alteration/Loss of consciousness
- Double vision
- Blurring of vision
• Signs
- Bradycardia
- Hypertension
- Meningismus
- Papilledema
- Terson syndrome
- Cranial nerve palsies
- Motor deficits

158. INVESTIGATIONS
•Non contrast CT Brain
•MRI Brain + MRA + MRV
•Lumbar Puncture
•DSA, MRA or CTA
• Basic blood routines
• USG Abdomen

162. MANAGEMENT
• Check vitals
• Check Airway, Breathing, Circulation
• Shift to ICU
• Target systolic Blood Pressure < 160 mm Hg
• Cerebroselective calcium channel blocker : Nimodipine – to prevent DCI
30 mg every 4 hours
• Analgesics
• Glucocorticoids : Dexamethasone – Headache, Neck stiffness
• Antiepileptic
• Management of aneurysm (if any)
• Monitor GCS, serum sodium

165. COILING CLIPPING

166. • 40 year old male presented with twitching of right upper limb
followed by tonic clonic convulsions. On examination, he has
tongue bite, post ictal confusion. Answer the following.
a) What is your diagnosis ? (2)
b) Classify seizures ? (3)
c) Where is the probable lesion ? (2)
d) How will you manage the patient ? (3)

167. • 40 year old male presented with twitching of right upper limb
followed by generalized tonic clonic convulsions for 5 minutes.
On examination, he has tongue bite, post ictal confusion.
Answer the following.
a) What is your diagnosis ? (2)
b) Classify seizures ? (3)
c) Where is the probable lesion ? (2)
d) How will you manage the patient ? (3)

168. DIAGNOSIS
•Status Epilepticus
Focal onset bilateral tonic-clonic
Left motor cortex lesion
Possibly structural etiology

170. CLASSIFICATION OF SEIZURES
Focal onset Generalized onset Unknown onset
- motor onset - motor onset
- non motor onset - non motor onset
- Preserved awareness
- Impaired awareness

171. MOTOR ONSET
•Focal
Tonic
Clonic
Atonic
Myoclonic
Epileptic spasms
Automatism
Generalized
Tonic
Clonic
Tonic – clonic
Atonic
Myoclonic
Epileptic spasms

172. NON-MOTOR ONSET
• Focal
Sensory
Autonomic
Emotional
Behavioral arrest
Generalized
Typical absence
Atypical absence

173. POSSIBLE SITE OF LESION
•Left motor cortex

174. MANAGEMENT OF THE PATIENT
•Check vitals
•Check Airway, Breathing, Circulation
•Left Lateral position
•Oxygen inhalation
•GRBS
•IV Cannula

175. FIRST LINE SECOND LINE
•IV Lorazepam
•IV Diazepam
•IM Midazolam
•Rectal Diazepam
•Phenytoin
•Fosphenytoin
•Levetiracetam
•Lacosamide
•Valproate

176. Phenytoin
• 20 mg/kg loading dose
• 50mg/minute
• In 100 ml normal saline
• Followed by 100 mg iv q8h

177. THIRD LINE
•Midazolam
•Propofol
•Pentobarbital
•Thiopental
•Ketamine
•Isoflurane

178. • 50 year old male with history of alcohol abuse for more than 15 years
presented with episodes of vomiting of blood and melena for last 1 day.
Wife also reports worsening of abdominal distension and jaundice since the
past 3 months. For the last 3 days, he also had irrelevant talk and and decreased sleep.
a) What is the likely diagnosis ? (2)
b) What are the causes of hemetesis ? (2)
c) What are the investigations to be done and expected abnormalities ? (3)
d) How do you manage this patient ? (3)

179. DIAGNOSIS
• Upper GI bleed
Jaundice
Encephalopathy
Decompensated Chronic Liver Disease – alcohol induced
Ascites with Portal Hypertension
Hepatic Encephalopathy
No evidence of SBP

180. Decompensation
•Jaundice
•Upper GI bleed : hematemesis, melena
•Ascites
•Hepatic encephalopathy

181. Causes of Hematemesis
• Mallory Weiss tear
• Gastritis & gastric erosions
• Peptic ulcer
• Portal Hypertension (Gastric & esophageal varices)
• Drug & toxin induced (eg: NSAID, Aspirin, Warfarin, Alcohol)
• Carcinoma stomach
• Cushing ulcer
• Curling ulcer
• Bleeding diathesis
• Angiodysplasia
• Hereditary hemorrhagic telangiectasia

182. INVESTIGATIONS
• Blood investigations
Anemia
Thrombocytopenia
Increased serum bilirubin
Increased AST & ALT
Increased GGT
Decreased serum albumin
Prolonged PT-INR
HBsAg, anti HCV
Serum ammonia
• Ascitic fluid analysis
TC, DC, Culture, SAAG, Cytology
• Ultrasonography
Surface nodularity
Increased echogenicity
Splenomegaly
Ascites
Increased diameter of portal vein
• Ultrasound elastography
Increased liver stiffness
• OGD scopy
Varices

183. TREATMENT
• Check vitals
• Check Airway, Breathing, Circulation
• Put two large bore iv lines
• NPO. Ryles tube aspiration
• IV Fluid administration : Normal saline
• PPI : High dose
• Blood Transfusion : Whole blood/PRBC, FFP
• Somatostatin & Vasopressin analogue (vasoactive agents) : Octerotide , Terlipressin

184. TREATMENT
• Antibiotic : Parenteral Ceftriaxone 1 gram iv for 7 days
• OGD : Endoscopic Variceal Ligation, Variceal sclerotherapy
• Bleeding not controlled : Balloon tamponade, TIPS
• Treatment for Hepatic encephalopathy : Lactulose, Rifaximin/Neomycin, LOLA
• Thiamine supplementation
• Secondary prophylaxis : Beta blocker
• Management of ascites : Spironolactone + Loop diuretic , LVP + Albumin, TIPS
• Liver Transplantation

188. TREATMENT OF GOUT

189. ECG CHANGES OF HYPERKALEMIA