Cardiology

Coronary artery anatomy

ECG interpretation
 Corresponding Coronary arteries
ST elevation on II, III, AVF
ST elevation on Leads V3-V4
ST elevation on Leads V1-V2
ST elevation on Leads I, AVL, V5-V6
ST depression on anterior and septal
leads with prominent R wave
Inferior MI (RCA occlusion)
Anterior MI (LAD occlusion)
Septal MI (LAD occlusion)
Lateral MI (left circumflex artery)
Posterior MI (posterior descending
artery)
ECG interpretation
ECG interpretation
ECG interpretation
ECG changes in potassium disorders

Hyperkalemia Hypokalemia
Low or absent P high P wave
Prolonged PR Slight PR prolongation
Wide QRS Depressed ST
Peaked T wave Broad flat T wave,
U wave
Prolonged QT interval
TIMI score for NSTEMI and UA
 Myocardial infarction treatment
A 61-year-old man presents with a 2-hour history of moderately severe
retrosternal chest pain, which does not radiate and is not affected by
respiration or posture. He complains of general malaise and nausea, but has
not vomited. His ECG shows ST segment depression and T wave inversion
in the inferior leads. Troponin levels are not elevated. He has already been
given oxygen, aspirin and intravenous GTN; he is an occasional user of
sublingual GTN and takes regular bisoprolol for stable angina. What would
be the most appropriate next step in his management?

a) IV low-molecular weight heparin

b) Thrombolysis with alteplase
c) IV nicardapine
d) Angiography with stenting
e) Oral clopidogrel
 Myocardial infarction treatment
A 49-year-old man is rushed to accident and emergency
complaining of a 20-minute history of severe, crushing
chest pain. After giving the patient glyceryl trinitrate
(GTN) spray, he is able to tell you he suffers from
hypertension and type 2 diabetes . The most appropriate
next in management is:
a) Aspirin
b) Morphine
c) Heparin
d) Clopidogrel
e) Warfarin
Congestive heart failure
Classification of Heart failure
 Rule of BNP
BNP (brain natriuretic peptide), is an enzyme, secreted by heart muscles due to
stretching of these muscles, it acts as a diuretic to decrease blood pressure and
decrease the load on the heart, useful to investigate if you are not sure if shortness
of breath is due to a cardiac or respiratory cause
- If BNP level is high (>500 pg/ml) cardiac cause
- If BNP not high  non-cardiac cause

Causes of high BNP:

- Heart failure
- Acute MI
- Mitral valve rupture
- Constrictive pericarditis
- Large pulmonary embolus
CXR showing cardiomegaly
Atrial fibrillation management
 Atrial fibrillation management
A 62-year-old male presents with palpitations, which are shown on ECG
to be atrial fibrillation with a ventricular rate of approximately
130/minute. He has mild central chest discomfort but is not acutely
distressed. He first noticed these about 3 hours before coming to hospital.
As far as is known this is his first episode of this kind. Which of the
following would you prefer as first-line therapy?

a) Anticoagulate with heparin and start Digoxin at standard daily dose

b) Attempt DC cardioversion
c) Administer bisoprolol and verapamil, and give warfarin
d) Attempt cardioversion with IV flecainide
e) Wait to see if there is spontaneous reversion to sinus rhythm.
Rheumatic fever
Erythema marginatum
 Question
55 years old male patient presented to ER recurrent angina and
sudden loss of consciousness and he was diagnosed with sever
aortic stenosis ,so he underwent Aortic valve replacement
surgery and in postoperative period patient started on
anticoagulation therapy By unfractionated Heparin. The best
test to follow up of this therapy is

a) Prothrombin Time (PT).

b) Partial Thromboplastin time (PTT).
c) International Normalize Ratio (INR).
d) Activated Clotting Time
e) Platelets Count
Target INR in different diseases treated
with warfarin
Respiratory system
PFT
 Test yourself!!
A 65-year-old male patient presented with SOB, he is a
heavy smoker and drinks alcohol on occasions,
Spirometry shows reduced FEV1 and normal FVC. Of
the following, what is the least likely diagnosis?

a) COPD
b) Asthma
c) Bronchiectasis
d) Kyphosis
 Asthma control
- SABA: Short-acting beta 2 agonist
o Used as the first line (as need)
o Example: salbutamol, albuterol, levalbuterol
o Used as reliever not controller (cause bronchodilation)
o Side effects include (hypokalemia, tachycardia, and tremor)
- ICS: Inhaled corticosteroid
o Used as add on if asthma not controlled on SABA alone
o Example: beclomethasone, fluticasone
o Used as a controller (preventer) but not used as a reliever (in acute asthma)
o Side effects include (dysphonia, oral candidiasis
- LTRA: Leukotriene receptor antagonist
o Oral medication (not inhaler) used to control asthma but not as a reliever
o Example: Montelukast
- LABA: Long-acting beta 2 agonists
o Used as controller not reliever
o Example: Salmeterol
- MART: Maintenance and reliever therapy
o Combined ICS and fast-acting LABA (Ex formoterol)
o Used as controller and reliever.
- Oral steroid:
o Can be used if the patient is on all above treatment and still not controlled
 Test yourself!
A 66-year-old male smoker is being evaluated for a persistent
cough and difficulty breathing. Spirometry confirms a fixed
obstructive pathology with an FEV of about 50% of predicted for
his size and age. His oxygen saturation is 89%-90% on room air.
Which one of the following would be most effective to prevent
worsening of this patient's condition?
a) A combined inhaled corticosteroid and long-acting Beta-
agonist
b) A long-acting anticholinergic agent
c) Long-term oral corticosteroids
d) Oxygen therapy
e) Smoking cessation.
ABG’s quick points
ABG’s additional steps
ABG’s examples
ABG’s examples
ABG’s examples
 Question
A 25-year-old woman complains of weight loss. She has a family
history of type 1 and type 2 diabetes but has never been
diagnosed herself . In the last few days, however, she has noticed
mild abdominal pain ,vomiting and progressively increasing
polyuria and poydipsia and 5 kg of weight loss. Her fasting
plasma glucose is 10 mmol/L and urine dipstick shows the
presence of ketones and ABGs shows ph 7,20 pco2 25 po2 90
Hco3 10 . The most likely diagnosis is:
a) Type 1 diabetes
b) Non-ketotic hyperosmolar state.
c) Type 2 diabetes
d) Insulinoma
e) Diabetic Ketoacidosis
 Anion gap
15 year old male patient known case of T1DM, presented with
abdominal pain and vomiting.
blood sugar was 560 mg/dl.
Serum K is 5.2 mEq/l, Na 127 mEq/l, Cl 105
ABG’s: PH= 6.9, HCO3 = 6, PaCo2 = 19
Calculate the anion gap for this patient.

Anoin gap = [Na+ K] – [Cl + HCO3]

CXR showing pneumonia
Poor prognostic factors of CAP

CURB65 score
CXR interpretation
CXR of upper lobe consolidation
Adverse effects of Anti-TB drugs
Pleural effusion
CXR interpretation
Asthma components
Asthma
Asthma
 Test yourself!
A 28-year-old man has been newly diagnosed with asthma. He
has been admitted to hospital with an asthma exacerbation and
experiences symptoms of respiratory distress. His peak
expiratory flow reading is currently 65 per cent of the normal
predicted value expected for his age and height. All of the
following are appropriate in management of his acute signs
and symptoms except,
a) Short-acting beta-2 agonist inhaler.
b) Short-acting anticholinergics inhaler.
c) Low-dose steroid orally.
d) High-dose steroid inhaler
e) High-dose steroid Intravenously
 COPD
The main difference between asthma and COPD is
variability and reversibility
The most common cause of COPD is smoking
COPD in young or nonsmoker patient  A1ATD
Gastroenterology
 Test yourself!!

A 40-year old female patient who is previously

healthy, presented with epigastric pain for 1 day
duration, this was associated with vomiting of food
containing, non-bilious, non-bloody vomits. Please
answer the following questions:
 Test yourself!!

What is the best initial test to do?

ECG
 Test yourself!!

If the pain is radiated to the back and

patient has epigastric tenderness on
examination, what would you do next?

Serum amylase
 Test yourself!!

If you suspect a gastric cause, and the

patient has anemia, weight loss, anorexia,
and night sweating, what would be your
next step?
Upper endoscopy
 Test yourself!!

If you suspect a gastric cause, and no alarm

signs are present, what would be your next
step?
Test for H. Pylori
 Test yourself!!

If H. pylori was negative, what would you

do next?

Start PPI (once daily)

 Test yourself!!

If the patient is not responsive to PPI, what

would you do next?

Increased PPI dose to twice daily

 Test yourself!!

If twice daily PPI is still not effective, what

would you do next?

Upper Endoscopy
 Diarrhea
A 23-year-old woman medical student, who has returned home from a
trip to India 1 day ago, presents to accident and emergency with profuse
bloody diarrhea. This started suddenly and she describes her stool as
being profuse and red color. She is unable to quantify the number of
times she has opened her bowels prior to presentation. On examination
her pulse is 110 bpm. Cardiorespiratory and gastrointestinal examination
are unremarkable. the most likely diagnosis can be any of the following
except,

a) Shigella
b) Typhoid
c) Pseudomembranous colitis
d) Cholera
e) Escherichia coli
 Bloody V.S. watery diarrhea
Bloody diarrhea Watery diarrhea
Infectious: Vibrio cholera
Bacterial: Enterohemorrhagic E. Coli, C. difficile
Salmonella, Shigella, Campylobacter, Giardiasis
Yersinia, C. difficile (less often Bacillus cereus
bloody), Staph aureus
Viruses: CMV
Parasites: Entamoeba histolytica,
Schistosomiasis
Ischemic Colitis
GI bleeding (AVMs, diverticulosis, brisk
UGI bleeds, etc.)
Medications: NSAIDs, chemotherapy
Inflammatory Bowel Disease
Diverticulitis
Cancer
Radiation
 IBD
A 29-year-old anxious man is diagnosed with mild Crohn’s
disease. Due to time constraints, the patient was asked to come
back for a follow-up appointment to discuss Crohn’s disease in
more detail. The patient returns with a list of complications he
researched on the internet. Which of the following are not
associated with Crohn’s disease?

a) Cigarette smoking increases incidence

b) Fistulae formation
c) Abscess formation
d) Caseating granuloma formation
e) Associated with transmural inflammation
Hepatology
LFT
Hepatitis B Markers

vaccine
HB- virus
 Test yourself!
A-25-year-old female recently immigrated and performed laboratory
checkups, she is up to date with her vaccinations. Her laboratory results
show, HBsAg negative, Anti-HBs positive and Anti-HBc positive with
negative HBeAg. Which of the following is the most appropriate
interpretation for her results?
a) Acute hepatitis B infection
b) Chronic inactive hepatitis B infection
c) Chronic active hepatitis B infection
d) Patient is vaccinated against hepatitis B
e) Patient in recovery phase from hepatitis B
f) Patient recovered from hepatitis B
Chronic liver disease
Spider Angioma
Caput medosae
Gynecomastia
Palmar erythema
Jaundice
 Jaundice
You see a 19-year-old Caucasian man in your clinic who presents
with a history of transient jaundice. On direct questioning, you
ascertain that the jaundice is noticeable after periods of increased
physical activity and subsides after a few days. The patient has no
other symptoms and physical examination is unremarkable. Full
blood count is normal (with a normal reticulocyte count) and liver
function tests reveal a bilirubin of 37 μmol/L. The most
appropriate management is:
a) Refer to Haematology
b) Start on a course of oral steroids
c) Request abdominal ultrasound
d) Request MRCP
e) Reassure and discharge home
Regarding Hepatic encephalopathy ,all of the following are true except,
a) It is a spectrum of neuropsychiatric abnormalities in patients with
advance liver dysfunction.
b) Hyperammonemia(NH3) plays a major role in pathogenesis.
c) Common Precipitants are Renal failure and Gastrointestinal bleeding.
d) Diuretic-induced hypovolemia is protective.
e) Lactulose , Neomycin and low-protein diets are used in management
Kayser-Fleischer-ring
Hematology
 Anemia classification
Microcytic anemia Normocytic anemia Macrocytic anemia
Iron deficiency Acute bleeding Megaloblastic
Anemia of chronic Anemia of chronic - B12 deficiency
disease Thalassemia disease Hemolysis - Folate deficiency,
Lead poisoning Renal/liver disease - Drugs that impair
Sideroblastic anemia Aplastic anemia DNA synthesis
MDS (methotrexate, sulfa,
Myelofibrosis chemotherapy)
Leukemia Non-Megaloblastic
Drugs (eg: - Liver disease
chemotherapy) - Alcoholism
- Hypothyroidism
- Myelodysplasia
 IDA
A 34-year-old female with menorrhagia is found to have iron-
deficiency anemia. Which one of the following is true regarding
the treatment of this problem with oral iron?
a) An acidic environment enhances the absorption of iron from
the gastrointestinal tract
b) Iron is absorbed better if taken with food
c) Diarrhea is a common complication
d) Iron supplementation can be discontinued once the
hemoglobin reaches a normal level
e) Sustained-release formulations increase the total amount of
iron available for absorption
 IDA
A 44-year-old Asian female presents with a two-month history of
shortness of breath and lethargy. She denies any intolerance to the
cold or any changes in her weight and on examination appears
slightly pale. She states that she has recently become a
vegetarian. A blood film shows the presence of elliptocytes and
blood results show the following: Haemoglobin 9.9 g/dL Mean
cell volume (MCV) 75 fL Ferritin 5 ng/mL The most likely
diagnosis is
a) Hereditary elliptocytosis
b) Sideroblastic anemia
c) Anemia of chronic disease
d) Thalassemias trait
e) Iron deficiency anemia
Koilonychia
 Quick points about clotting factors
Blood Proteins:
- Composed of clotting factors and transportants in the blood
- All clotting factors are synthesized in the liver except factors 8,
vWF, and thromboplastin are synthesized in the endothelium
- Factor VII has the shortest half-life
- Vitamin K dependent clotting factors are (X, IX, VII, II, protein
C, S, Z)
- Factor 13 cause bleeding tendency without increasing in PT. or
PTT
- Factor 12 cause increase in PTT but without a bleeding tendency
Types of heparin
Warfarin vs heparin
HIT syndrome
Nephrology
Renal impairment
Endocrinology
T1DM VS T2DM
 Diagnosis of DM

Diagnosis of DM: any one of the following is diagnostic:

•Symptoms of DM + RBS ≥ 200 mg/dl or,
•One of the following On at least two separate occasions:
1.FBS ≥ 126 mg/dl
2.2h 75 g OGTT ≥ 200 mg/dl
3.RBS ≥ 200 mg/dl
4.HbA1c ≥ 6.5%
 Treatment of DM
•T1DM is insulin dependent and not responsive to oral hypoglycemic
agents, BUT New studies show benefit from adding metformin
•T2DM should be started initially on lifestyle modifications with proper
diet, exercise and weight loss, 50% of patient will achieve A1c target
without medications
If no improvement  can be started at oral agents and may be switched
to insulin if target A1C can't be achieved
•Initial HbA1c of 9% or more indicate starting insulin
•Checking HbA1c every 3 months to assess the adequacy of treatment
and titration of doses
 Treatment of DM
A 38 year old female patient ,who has BMI 29 and type 2 diabetes
mellitus, she has been taking metformin with good effect for the last four
months. He has started to lose weight and maintained good glucose
control. In the last two months, however, the patient has been persistently
hyperglycemic despite increased metformin dosage and HbA1c targets
have not been achieved and now HbA1c is 8.5 % . The most appropriate
management is:

a) Add Thiazolidinedione
b) Add Insulin therapy
c) Add Sulfonylurea
d) Increase metformin dose
e) Add Exenatide
 Test yourself!!

45 years old woman with DM type 2, which is well controlled,

her physical examination is positive for peripheral neuropathy in
the feet and non-proliferative retinopathy. Urinalysis is positive
for proteinuria. One of the following treatments is positive for
attenuate the course of renal disease:
a) Beta-blockers
b) ACE inhibitors
c) HMG-CoA inhibitor
d) Dietary carbohydrate restriction
e) Weight reduction
DKA vs HHS
Hypothyroidism vs Hyperthyroidism
 Graves disease
A 35-year-old woman presents with visual disturbances. She
reports having double vision which was intermittent initially but
has now become much more frequent. In addition, she becomes
breathless very easily and experiences palpitations. On
examination, raised, painless lesions are observed on the front of
her shins and finger clubbing. The most specific test to make the
expected diagnosis is,

a) Serum free T3 level.

b) Serum Free T4 level.
c) Serum TSH level.
d) Serum Thyroid Stimulating Immunoglobulin.
e) Serum Total T4 level.
 Question
A 42-year-old woman presents with visual disturbances. She reports
having double vision which was intermittent initially but has now
become much more frequent. In addition, she becomes breathless very
easily and experiences palpitations. On examination, raised, painless
lesions are observed on the front of her shins and finger clubbing, All of
the following are true about this condition except,
a) This condition is due to IgG antibodies binding to the TSH receptor.
b) This condition associated with multinodular Goiter.
c) This condition associated with pernicious anemia and High serum
T3,T4.
d) This condition in long term can lead to osteoporosis.
e) The most commonly used therapy for this condition is radioactive
iodine.
 Question
A 44-year-old woman ,known to have grave's disease for which she
underwent radioactive iodine therapy, presents to her GP complaining of
a change in her breathing sound. She first noticed numbness, particularly
in her fingers and toes, three months ago but attributed this to the cold
weather. Her partner now reports hearing a high pitched, harsh sound
while she is sleeping. Her BMI is 27. While measuring blood pressure,
you notice the patient’s wrist flexing. The most likely diagnosis is:
a) Obstructive sleep apnea
b) Secondary Hypoparathyroidism
c) Primary Hypoparathyroidism
d) Guillain–Barré syndrome
e) Raynaud’s syndrome
Miscellaneous
Clubbing
Test yourself !!
 Mood of inheritance
The following link contains most common
inherited diseases with their mood of
inheritance
https://www.kumc.edu/AMA-MSS/Study/table_of_genetic_disorders.htm
 Watch videos on YouTube
• https://www.youtube.com/channel/UCEEtcBy
nI7bv0yBBt0s-l0w
Thank you

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@Amjadafeef

Amjad Al-Afeef

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