BDS General Medicine Syllabus

Define COPD and name its two main components.

Chronic Obstructive Pulmonary Disease is a progressive, largely irreversible airflow limitation. Its two components are chronic bronchitis (productive cough $\geq 3$ months per year for 2 consecutive years) and emphysema (destruction/enlargement of alveolar air spaces).

What is the single most important risk factor for COPD, and which spirometry ratio confirms obstruction?

Cigarette smoking is the leading risk factor. Airflow obstruction is confirmed by a post-bronchodilator $\frac{FEV_{1}}{FVC} < 0.70$.

Contrast the classic 'pink puffer' and 'blue bloater' phenotypes in COPD.

Pink puffer (emphysema-predominant): thin, marked dyspnoea, pursed-lip breathing, relatively preserved oxygenation. Blue bloater (chronic bronchitis-predominant): cyanosis, productive cough, hypoxaemia, hypercapnia, and cor pulmonale/oedema.

Define asthma and describe its core pathophysiology.

A chronic inflammatory airway disorder causing reversible airflow obstruction. It features bronchial hyper-responsiveness, reversible bronchoconstriction, airway inflammation (eosinophilic), mucus hypersecretion, and airway remodeling.

How does spirometry reversibility distinguish asthma from COPD?

In asthma, airflow obstruction is reversible: $FEV_{1}$ improves by $\geq 12\%$ and $\geq 200$ mL after a bronchodilator. In COPD, obstruction is largely fixed/irreversible with little post-bronchodilator improvement.

What are the first-line reliever and controller medications for asthma?

Reliever: short-acting beta-2 agonist (SABA, e.g., salbutamol) for acute symptoms. Controller (preventer): inhaled corticosteroids (ICS), often combined with a long-acting beta-2 agonist (LABA) for persistent asthma.

List the danger (life-threatening) signs in an acute severe asthma attack.

Silent chest, cyanosis, feeble respiratory effort, exhaustion/confusion, bradycardia or hypotension, $PEF < 33\%$ predicted, $SpO_{2} < 92\%$, and a normal or rising $PaCO_{2}$ (a sign of impending respiratory failure).

Define pneumonia and distinguish community-acquired from hospital-acquired pneumonia.

Pneumonia is infection/inflammation of the lung parenchyma with alveolar consolidation. Community-acquired (CAP): onset in the community or within 48 h of admission. Hospital-acquired (HAP): onset $> 48$ h after hospital admission, often with resistant organisms.

What is the most common bacterial cause of community-acquired pneumonia?

Streptococcus pneumoniae (pneumococcus) is the most common cause of typical community-acquired pneumonia.

What does the CURB-65 score assess and what are its components?

It assesses severity/mortality risk in community-acquired pneumonia to guide admission. Components (1 point each): Confusion, Urea $> 7$ mmol/L, Respiratory rate $\geq 30$/min, Blood pressure ($SBP < 90$ or $DBP \leq 60$ mmHg), Age $\geq 65$.

Contrast typical and atypical pneumonia presentations.

Typical (e.g., S. pneumoniae): acute onset, high fever, productive purulent sputum, lobar consolidation. Atypical (e.g., Mycoplasma, Legionella, Chlamydophila): gradual onset, dry cough, prominent extrapulmonary/systemic symptoms, and patchy interstitial infiltrates.

Define pulmonary embolism and its most common source.

Occlusion of a pulmonary artery (or branch) by material, usually a thrombus. The most common source is a deep vein thrombosis (DVT) of the lower limb or pelvis that embolises to the lungs.

Name the components of Virchow's triad predisposing to venous thromboembolism.

Venous stasis, endothelial (vessel wall) injury, and hypercoagulability.

What is the role of the D-dimer test and the definitive imaging in suspected pulmonary embolism?

D-dimer has high sensitivity but low specificity; a normal D-dimer helps exclude PE in low-probability patients. The definitive/confirmatory investigation is CT pulmonary angiography (CTPA); a V/Q scan is an alternative.

What is the classic ECG finding described in pulmonary embolism (though the most common is sinus tachycardia)?

The classic pattern is $S1Q3T3$ — a prominent S wave in lead I, a Q wave and inverted T wave in lead III. However, the most common ECG finding is simply sinus tachycardia.

Define peptic ulcer disease and name its two most important causes.

A break in the mucosa of the stomach or duodenum extending through the muscularis mucosae. The two leading causes are Helicobacter pylori infection and NSAID use.

How do the pain patterns of gastric versus duodenal ulcers classically differ with food?

Gastric ulcer pain is typically worsened by eating (weight loss common). Duodenal ulcer pain is classically relieved by food and worsens when hungry or at night, 2-3 hours after meals.

What is the mainstay drug therapy for peptic ulcer disease, and how is H. pylori eradicated?

Proton pump inhibitors (PPIs) suppress acid to promote healing. H. pylori is eradicated with triple therapy: a PPI plus two antibiotics (commonly amoxicillin and clarithromycin) for 7-14 days.

Compare Crohn's disease and ulcerative colitis in Inflammatory Bowel Disease.

Crohn's: affects mouth-to-anus (skip lesions), transmural inflammation, non-caseating granulomas, cobblestone mucosa, fistulae/strictures. Ulcerative colitis: confined to colon/rectum, continuous mucosal/submucosal inflammation, crypt abscesses, bloody diarrhoea, no granulomas.

Which IBD is associated with smoking as a risk factor, and which is paradoxically improved by smoking?

Smoking worsens/is a risk factor for Crohn's disease, whereas ulcerative colitis is more common in non-smokers/ex-smokers and may paradoxically be less severe in smokers.

Define liver cirrhosis pathologically.

Irreversible, diffuse hepatic fibrosis with conversion of normal architecture into structurally abnormal regenerative nodules, resulting from chronic liver injury. It is the end stage of chronic liver disease.

List the major complications of decompensated cirrhosis.

Portal hypertension leading to oesophageal varices (bleeding), ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, coagulopathy, and hepatocellular carcinoma.

What does the Child-Pugh score use to assess cirrhosis severity?

It grades cirrhosis (classes A, B, C) using five parameters: serum Bilirubin, serum Albumin, Prothrombin time/INR, Ascites, and hepatic Encephalopathy.

Compare the transmission routes of hepatitis A, B, and C viruses.

Hepatitis A: faecal-oral (contaminated food/water), acute only. Hepatitis B: blood, sexual, and vertical (perinatal) transmission, can be chronic. Hepatitis C: predominantly blood-borne (IV drug use), high rate of chronic infection.

Which hepatitis serological marker indicates immunity, and which indicates active/current infection in hepatitis B?

Anti-HBs (surface antibody) indicates immunity (from vaccination or recovery). HBsAg (surface antigen) indicates active/current infection, and HBeAg indicates high infectivity/active replication.

Define stroke and distinguish the two main types.

Stroke is an acute focal neurological deficit from a vascular cause lasting $> 24$ hours. Ischaemic stroke (about 85%): occlusion of a cerebral vessel (thrombosis/embolism). Haemorrhagic stroke (about 15%): rupture of a vessel causing intracerebral or subarachnoid bleeding.

What is a transient ischaemic attack (TIA) and why is it important?

A transient focal neurological deficit due to temporary ischaemia, resolving fully (classically within 24 hours) without infarction. It is important as a warning sign of high subsequent stroke risk, requiring urgent evaluation.

What is the key acute treatment for ischaemic stroke and its time window?

IV thrombolysis with alteplase (tPA), ideally given within 4.5 hours of symptom onset after haemorrhage is excluded on imaging. Mechanical thrombectomy is used for large-vessel occlusion, generally up to 6-24 hours in selected patients.

Define epilepsy and distinguish focal from generalized seizures.

Epilepsy is a tendency to recurrent, unprovoked seizures from abnormal excessive neuronal discharge. Focal (partial) seizures begin in one hemisphere/region (may have preserved or impaired awareness); generalized seizures involve both hemispheres from onset (e.g., tonic-clonic, absence).

Define status epilepticus and state its emergency first-line drug.

A seizure lasting $> 5$ minutes, or recurrent seizures without recovery of consciousness between them. It is a medical emergency; first-line treatment is a benzodiazepine (IV lorazepam or diazepam, or buccal/IM midazolam).

What is the core pathology of Parkinson's disease and its classic triad of signs?

Degeneration of dopaminergic neurons in the substantia nigra pars compacta (with Lewy bodies), reducing striatal dopamine. Classic triad: resting tremor (pill-rolling), rigidity (cogwheel), and bradykinesia; postural instability is a fourth cardinal feature.

What is the most effective drug treatment for Parkinson's disease and why is it combined with carbidopa?

Levodopa (L-DOPA), a dopamine precursor that crosses the blood-brain barrier. It is combined with carbidopa (a peripheral DOPA-decarboxylase inhibitor) to prevent peripheral conversion, reduce side effects, and increase central availability.

Define multiple sclerosis and its underlying pathology.

A chronic autoimmune, inflammatory, demyelinating disease of the CNS in which the immune system attacks myelin, causing plaques/lesions disseminated in space and time. This slows/blocks nerve conduction, producing relapsing-remitting or progressive neurological deficits.

What is Uhthoff's phenomenon in multiple sclerosis?

Transient worsening of MS symptoms (e.g., blurred vision) with an increase in body temperature, such as during exercise, fever, or a hot bath, due to heat-sensitive slowing of conduction in demyelinated fibres.

Define acute kidney injury (AKI) and its three categories by cause.

AKI is a rapid decline in renal function over hours to days, with rising creatinine and/or reduced urine output. Causes: pre-renal (hypoperfusion), intrinsic/renal (e.g., acute tubular necrosis), and post-renal (obstruction of urine outflow).

State the diagnostic criteria for AKI (KDIGO).

AKI is diagnosed by any of: rise in serum creatinine $\geq 26.5$ µmol/L within 48 hours; a $\geq 1.5$-fold rise in creatinine from baseline within 7 days; or urine output $< 0.5$ mL/kg/h for $\geq 6$ hours.

Define chronic kidney disease and how it is staged.

CKD is abnormal kidney structure or function present for $\geq 3$ months. It is staged by GFR: G1 $\geq 90$, G2 60-89, G3a 45-59, G3b 30-44, G4 15-29, G5 $< 15$ mL/min/1.73m² (kidney failure), combined with albuminuria (A1-A3).

Write the eGFR/creatinine clearance concept and name the classic Cockcroft-Gault formula components.

GFR estimates filtering capacity. Cockcroft-Gault estimates creatinine clearance: $$CrCl = \frac{(140 - age) \times weight \times (0.85\ if\ female)}{72 \times serum\ creatinine\ (mg/dL)}$$

List the common metabolic and systemic consequences of chronic kidney disease.

Anaemia (reduced erythropoietin), renal bone disease/CKD-MBD (hyperphosphataemia, low vitamin D, secondary hyperparathyroidism), metabolic acidosis, hyperkalaemia, fluid overload/hypertension, and increased cardiovascular risk.

What ECG changes are associated with hyperkalaemia, a key danger in acute and chronic kidney disease?

Progressive changes: tall peaked T waves, then flattened/absent P waves and prolonged PR, widening of the QRS complex, and ultimately a sine-wave pattern leading to ventricular fibrillation or asystole.

What is cor pulmonale and which chronic lung disease commonly causes it?

Cor pulmonale is right ventricular hypertrophy and/or failure secondary to pulmonary hypertension from a chronic lung disorder. COPD is a common cause, via chronic hypoxaemia causing pulmonary vasoconstriction and increased right ventricular afterload.