SMLE Medicine Syllabus

Medicine syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Medicine in SMLE, not a summary of it.

1. 1

   Cardiology

   3 topics

   • Ischemic Heart Disease
   • Heart Failure
   • Arrhythmias
2. 2

   Respiratory

   3 topics

   • Chronic Obstructive Pulmonary Disease
   • Asthma
   • Pneumonia

Medicine flashcards for SMLE

21 of 51 cards from the Medicine deck — real questions with worked answers.

1. What is the underlying pathophysiology of ischemic heart disease (IHD)?

   An imbalance between myocardial oxygen supply and demand, most often caused by atherosclerotic narrowing of the coronary arteries, leading to myocardial ischemia.

2. Differentiate stable angina from unstable angina based on symptom pattern.

   Stable angina: predictable chest pain on exertion, relieved by rest or nitroglycerin within minutes. Unstable angina: new-onset, rest, or crescendo pain that is more frequent/severe and NOT reliably relieved by rest — an acute coronary syndrome.

3. How do you distinguish unstable angina from NSTEMI?

   Both show no persistent ST elevation. Unstable angina has NORMAL cardiac troponins, whereas NSTEMI shows ELEVATED troponins (myocardial necrosis has occurred).

4. What ECG finding defines STEMI, and what does it indicate?

   Persistent ST-segment elevation (or new left bundle branch block) indicating full-thickness (transmural) myocardial infarction from complete coronary occlusion.

5. Which cardiac biomarker is most sensitive and specific for myocardial infarction, and its time course?

   Cardiac troponin (T or I). It rises within 3-4 hours, peaks at ~24-48 hours, and remains elevated for up to 7-14 days.

6. What is the reperfusion strategy of choice for STEMI and its key time targets?

   Primary percutaneous coronary intervention (PCI). Target door-to-balloon time <90 minutes; if PCI is unavailable, give fibrinolysis within 30 minutes (door-to-needle) provided presentation is within 12 hours of symptom onset.

7. List the components of initial medical therapy (MONA-BASH) for acute coronary syndrome.

   Morphine (if needed), Oxygen (if $SaO_2 < 90\%$), Nitrates, Aspirin, plus Beta-blocker, ACE inhibitor, Statin (high-intensity), and Heparin/anticoagulation. Add a second antiplatelet (P2Y12 inhibitor) for dual antiplatelet therapy.

8. ECG leads II, III, and aVF show ST elevation. Which artery and wall are affected?

   Inferior wall myocardial infarction, usually from occlusion of the right coronary artery (RCA).

9. Which coronary artery supplies the anterior wall, and which leads show its infarction?

   The left anterior descending (LAD) artery; anterior MI shows ST changes in the precordial leads $V_1$-$V_4$.

10. Define heart failure.

    A clinical syndrome in which the heart cannot pump blood at a rate sufficient to meet the metabolic demands of tissues, or can do so only at elevated filling pressures.

11. How are HFrEF and HFpEF distinguished by ejection fraction?

    HFrEF (reduced EF / systolic failure): $LVEF \leq 40\%$. HFpEF (preserved EF / diastolic failure): $LVEF \geq 50\%$ with impaired ventricular relaxation. An EF of 41-49% is HF with mildly reduced EF.

12. State the formula for ejection fraction.

    $$EF = \frac{SV}{EDV} \times 100\% = \frac{EDV - ESV}{EDV} \times 100\%$$ where $SV$ is stroke volume, $EDV$ end-diastolic volume, and $ESV$ end-systolic volume. Normal is $\geq 55\%$.

13. Contrast the typical clinical features of left-sided versus right-sided heart failure.

    Left-sided: pulmonary congestion — dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulmonary crackles. Right-sided: systemic congestion — peripheral edema, raised JVP, hepatomegaly, ascites.

14. Which biomarker aids in diagnosing heart failure and what does a low value suggest?

    BNP (or NT-proBNP), released from stretched ventricular myocardium. A low/normal BNP has a high negative predictive value, effectively ruling out heart failure as the cause of dyspnea.

15. Name the four drug classes proven to reduce mortality in HFrEF (the 'four pillars').

    1) ARNI or ACE inhibitor/ARB, 2) Beta-blocker, 3) Mineralocorticoid receptor antagonist (e.g., spironolactone), 4) SGLT2 inhibitor. Diuretics relieve congestion but do not improve mortality.

16. Describe the NYHA functional classification of heart failure.

    Class I: no symptoms with ordinary activity. Class II: slight limitation, symptoms with ordinary activity. Class III: marked limitation, symptoms with less-than-ordinary activity. Class IV: symptoms at rest.

17. What compensatory mechanism initially maintains cardiac output in heart failure but becomes maladaptive?

    Neurohormonal activation — the sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS). Chronically they cause vasoconstriction, salt/water retention, and adverse cardiac remodeling.

18. State the relationship between cardiac output, heart rate, and stroke volume.

    $$CO = HR \times SV$$ Cardiac output equals heart rate multiplied by stroke volume (normal resting $CO \approx 4$-$8\ \text{L/min}$).

19. What is the most common sustained cardiac arrhythmia, and its hallmark ECG features?

    Atrial fibrillation. ECG shows an irregularly irregular rhythm with absent P waves and a fibrillating (chaotic) baseline.

20. What scoring system guides anticoagulation in atrial fibrillation, and its components?

    $CHA_2DS_2$-VASc: Congestive HF, Hypertension, Age $\geq 75$ (2 points), Diabetes, prior Stroke/TIA (2 points), Vascular disease, Age 65-74, Sex category (female). Anticoagulate when the score is $\geq 2$ in men or $\geq 3$ in women.

21. Differentiate first-, second-, and third-degree AV block.

    First-degree: PR interval prolonged $> 200\ \text{ms}$, all beats conducted. Second-degree Mobitz I (Wenckebach): progressive PR lengthening until a dropped beat; Mobitz II: intermittent dropped beats with constant PR. Third-degree (complete): total AV dissociation — atria and ventricles beat independently.

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