PMDC National Licensing Examination Medicine and Allied Syllabus

Define a hypertensive emergency versus urgency.

Hypertensive emergency: severely elevated BP (often >180/120) WITH acute end-organ damage, requiring IV agents and controlled reduction. Urgency: severe BP without acute end-organ damage, managed with oral agents over hours-days.

Name common secondary causes of hypertension to screen for in young or resistant patients.

Renal artery stenosis, chronic kidney disease, primary hyperaldosteronism (Conn syndrome), pheochromocytoma, Cushing syndrome, coarctation of the aorta, and obstructive sleep apnea.

What murmur and characteristics define aortic stenosis?

An ejection systolic, crescendo-decrescendo murmur at the right upper sternal border radiating to the carotids, with a slow-rising low-volume pulse and narrow pulse pressure; classic triad: angina, syncope, dyspnea.

What murmur characterizes mitral regurgitation?

A pansystolic (holosystolic) murmur loudest at the apex, radiating to the axilla.

What are the major (Jones criteria) features of acute rheumatic fever?

Major: Joints (migratory polyarthritis), Carditis (O - pancarditis), Nodules (subcutaneous), Erythema marginatum, Sydenham chorea (mnemonic JONES/CASES). Caused by Group A Streptococcus.

Which valvular lesion is the most common chronic sequela of rheumatic heart disease?

Mitral stenosis - producing a mid-diastolic rumbling murmur with an opening snap, best heard at the apex in the left lateral position.

What antibiotic prophylaxis prevents recurrent rheumatic fever?

Long-term benzathine penicillin G (intramuscular every 3-4 weeks) for secondary prophylaxis.

What is the key spirometry finding distinguishing obstructive from restrictive lung disease?

Obstructive: reduced FEV1/FVC ratio (<0.7) with reduced FEV1 (e.g., asthma, COPD). Restrictive: normal or increased FEV1/FVC ratio with reduced FVC and total lung capacity.

What reversibility test helps differentiate asthma from COPD?

Asthma shows significant bronchodilator reversibility (FEV1 improves >=12% and >=200 mL after a bronchodilator); COPD shows little or no reversibility (largely fixed airflow obstruction).

Outline the stepwise pharmacologic management of chronic asthma.

Step 1: SABA as needed (now often ICS-formoterol PRN). Add low-dose inhaled corticosteroid (ICS); then add a LABA (combination ICS/LABA); increase ICS dose; add LTRA/LAMA; finally oral steroids/biologics for severe disease.

List signs of life-threatening acute severe asthma.

Silent chest, cyanosis, exhaustion/confusion, bradycardia/hypotension, PEF <33% predicted, SpO2 <92%, and a normal or rising PaCO2 (sign of impending respiratory failure).

What is the main mechanism and most important risk factor for COPD?

Chronic inflammation causing irreversible airflow limitation (emphysema plus chronic bronchitis); the most important risk factor is cigarette smoking (alpha-1 antitrypsin deficiency in young/non-smokers).

Which COPD patients qualify for long-term oxygen therapy (LTOT) and what is the survival benefit threshold?

Patients with chronic PaO2 <=7.3 kPa (55 mmHg), or <=8.0 kPa (60 mmHg) with cor pulmonale/polycythemia; LTOT used >=15 hours/day improves survival.

What is the CURB-65 score and what does it assess?

A severity score for community-acquired pneumonia: Confusion, Urea >7 mmol/L, Respiratory rate >=30, Blood pressure <90 systolic or <=60 diastolic, age >=65. Each point = 1; higher scores indicate need for hospital/ICU admission.

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

Streptococcus pneumoniae (pneumococcus).

Match the atypical pneumonia organism to its classic clue: cold agglutinins; air-conditioning/water with hyponatremia; bird exposure.

Cold agglutinins/erythema multiforme: Mycoplasma pneumoniae. Air-conditioning/water source with hyponatremia and deranged LFTs: Legionella pneumophila. Bird exposure: Chlamydia psittaci (psittacosis).

Which organism classically causes cavitating pneumonia in alcoholics with 'red-currant jelly' sputum?

Klebsiella pneumoniae.

What organism causes tuberculosis and what stain identifies it?

Mycobacterium tuberculosis, an acid-fast bacillus identified by the Ziehl-Neelsen stain (or auramine fluorescence).

What is the standard first-line drug regimen and duration for drug-sensitive pulmonary TB?

2 months of RIPE (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) followed by 4 months of Rifampicin and Isoniazid - total 6 months.

Match each first-line anti-TB drug to its key adverse effect: Isoniazid, Rifampicin, Pyrazinamide, Ethambutol.

Isoniazid: peripheral neuropathy (give pyridoxine/B6) and hepatitis. Rifampicin: orange body fluids, hepatitis, enzyme induction. Pyrazinamide: hepatotoxicity and hyperuricemia/gout. Ethambutol: optic neuritis (color vision loss).

What test confirms latent TB infection?

Tuberculin skin test (Mantoux) or an interferon-gamma release assay (IGRA, e.g., QuantiFERON); these indicate immune sensitization without active disease.

Differentiate transudate from exudate using Light's criteria.

Exudate if any: pleural/serum protein ratio >0.5, pleural/serum LDH ratio >0.6, or pleural LDH >2/3 the upper limit of normal serum LDH. Transudate fails all (low protein, e.g., heart failure, cirrhosis); exudate from inflammation/infection/malignancy.

Give two common causes each of transudative and exudative pleural effusions.

Transudative: heart failure, cirrhosis/hypoalbuminemia, nephrotic syndrome. Exudative: pneumonia (parapneumonic), malignancy, TB, pulmonary embolism.

What is a tension pneumothorax and its immediate management?

Air trapped in the pleural space under pressure causing mediastinal shift, tracheal deviation away from the side, distended neck veins, and hemodynamic collapse. Immediate treatment: emergency needle decompression (2nd intercostal space, midclavicular line) then chest drain - do NOT wait for x-ray.

Which patient profile is typical for primary spontaneous pneumothorax?

A tall, thin young male smoker, due to rupture of apical subpleural blebs.

What is the major modifiable cause of peptic ulcer disease and how is it diagnosed non-invasively?

Helicobacter pylori infection (plus NSAID use); diagnosed non-invasively by urea breath test or stool antigen test.

What is the triple therapy regimen for H. pylori eradication?

A proton pump inhibitor plus two antibiotics (typically amoxicillin and clarithromycin, or metronidazole) for 7-14 days.

Compare gastric and duodenal ulcer pain in relation to food.

Gastric ulcer: pain worsens with eating (weight loss). Duodenal ulcer: pain relieved by eating and worse at night/when hungry (weight stable/gain).

What scoring tools assess upper GI bleeding risk?

Glasgow-Blatchford score (pre-endoscopy, predicts need for intervention) and the Rockall score (post-endoscopy, predicts rebleeding and mortality).

Name the most common cause of chronic liver disease worldwide and the classic stigmata of chronic liver disease.

Common causes: alcohol, viral hepatitis (B and C), and NAFLD/MASLD. Stigmata: spider naevi, palmar erythema, gynecomastia, jaundice, ascites, caput medusae, asterixis, and Dupuytren contracture.

How are hepatitis B serology markers interpreted (HBsAg, anti-HBs, anti-HBc IgM, HBeAg)?

HBsAg+: current infection. Anti-HBs+: immunity (vaccination or recovery). Anti-HBc IgM+: acute infection. Anti-HBc IgG+: past/chronic exposure. HBeAg+: high infectivity/active replication.

Contrast ulcerative colitis and Crohn disease by distribution and depth of involvement.

Ulcerative colitis: continuous, mucosal/submucosal inflammation limited to the colon, starting at the rectum. Crohn disease: skip lesions with transmural inflammation anywhere from mouth to anus (commonly terminal ileum), with granulomas, fistulae, and strictures.