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GI Joe Medical Boards

GI Joe Medical Boards

By: Joseph Kumka
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 I'm Dr. Joseph Kumka, Gastroenterology Fellow, educator, and host of evidence-based, board-oriented medical podcasts. Whether you're a resident gearing up for the boards, a fellow diving deep into subspecialty topics, or a practicing clinician hungry for high-yield updates—you’re in the right place.2025 Hygiene & Healthy Living Physical Illness & Disease
Episodes
  • Cardiology - Acute Coronary Syndromes (ACS)

    Cardiology - Acute Coronary Syndromes (ACS)
    Jun 24 2025
    ACUTE CORONARY SYNDROMES (ACS)Initial EvaluationAssess Symptoms: Obtain history of substernal or left-sided chest discomfort, pain, or pressure, potentially radiating to the left arm, neck, or jaw. Inquire about accompanying dyspnea, nausea, vomiting, diaphoresis, lightheadedness, or palpitations. Consider Atypical Presentations: Be vigilant for atypical symptoms or "silent MI," particularly in women, older individuals, and patients with diabetes.Perform Focused Physical Examination:Vascular Assessment: Check for signs of extracardiac atherosclerosis (carotid or peripheral bruits).Cardiac & Hemodynamic Status: Auscultate for an S4 (impaired LV compliance) or S3, and rales, jugular venous distension, or edema (signs of heart failure). Note hypertension (due to adrenergic stimulation) or hypotension.Mechanical Complications: If hypotensive, actively look for new murmurs of mitral regurgitation (MR) or a ventricular septal defect (VSD), often with a palpable thrill.Right Ventricular (RV) Infarct: Suspect RV infarct if there is elevated jugular venous pressure (JVP), clear lung fields, and hypotension.Order Immediate Diagnostic Tests:12-Lead EKG: Obtain immediately to differentiate between NSTE-ACS and STEMI (or equivalent entities). If STEMI (or equivalent): Look for acute ST-segment elevations: ≥2 mm in men or ≥1.5 mm in women in leads V2–V3, or ≥1 mm in other leads in two contiguous leads. A new Left Bundle Branch Block (LBBB) is considered a STEMI equivalent. Consider an old LBBB with new ST deviations ≥1 mm concordant or ≥5 mm discordant as equivalent.If NSTE-ACS: Evaluate for ST-segment depressions, T-wave inversions or flattening, or nonspecific ST- and T-wave changes. Note dynamic EKG changes that correlate with chest discomfort, which are highly suggestive of ischemia.Cardiac Biomarkers: Order cardiac-specific troponins T and I immediately; these are the preferred biomarkers for diagnosing MI. Consider serial CK-MB levels for detecting reinfarction after initial MI, as they normalize more quickly.Initiate Continuous EKG Monitoring: Place the patient on continuous EKG monitoring to screen for ischemia and rhythm changes.Emergent ActionsBed Rest: Enforce immediate bed rest to reduce myocardial oxygen demand.Supplemental Oxygen: Administer supplemental oxygen if the oxygen saturation is <90%.Sedation/Anxiolytics: Consider sedation to decrease anxiety and catecholaminergic stimulation. Morphine may be used for refractory chest discomfort or in the presence of heart failure.Reperfusion Therapy for STEMI (or equivalent): This is critical for myocardial salvage and improved survival. If at a PCI-Capable Hospital: Perform Percutaneous Coronary Intervention (PCI) within 90 minutes of first medical contact.If Transferring to a PCI-Capable Hospital: Aim for PCI initiation within 120 minutes of first medical contact.If PCI Cannot Be Initiated within 120 Minutes AND <12 Hours Since Symptom Onset: Administer fibrinolysis within 30 minutes of first medical contact unless contraindicated. Absolute Contraindications to Fibrinolysis: Prior intracranial hemorrhage (ICH), intracranial neoplasm or AVM, ischemic CVA within the last 3 months (except ischemic stroke in the last 4.5 hours), suspected aortic dissection, active internal bleed (except menses), significant closed-head or facial trauma in last 3 months, intracranial or intraspinal surgery in last 2 months, severe uncontrolled hypertension refractory to therapy.Consider PCI regardless of time from symptom onset in the setting of heart failure or cardiogenic shock.If Ongoing Ischemia After Fibrinolysis: Proceed with rescue PCI.Diagnostics (Beyond Initial EKG and Biomarkers)Coronary Angiography (Cardiac Catheterization): This is the gold standard for defining severity and extent of coronary artery disease and is central to invasive management strategies. For NSTE-ACS, Risk Stratify for Timing of Angiography:Very High Risk (Immediate Invasive Strategy: within 2 hours): Patients with refractory angina, signs of heart failure, life-threatening ventricular arrhythmias (e.g., sustained VT/VF), or a high GRACE risk score.Intermediate-to-High Risk (Early Invasive Strategy: within 24 hours): Patients with an elevated GRACE risk score (>140), dynamic EKG changes, elevated cardiac biomarkers, recurrent ischemia or angina, EF <40%, hemodynamic or arrhythmic instability, pulmonary edema, diabetes, or renal insufficiency.Intermediate Risk (Delayed Invasive Approach: within 24-72 hours): Patients with an intermediate TIMI or GRACE risk score, diabetes, renal insufficiency, or LV dysfunction.Low Risk (Conservative/Ischemia-Guided Strategy): Patients who are troponin-negative with no high-risk clinical features. These patients should undergo a pre-discharge stress test. Angiography is reserved for those who fail medical therapy or demonstrate objective evidence of recurrent ischemia.Echocardiography: Useful for assessing cardiac structure and function, valve ...
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    22 mins
  • Cardiology - Arrhythmias

    Cardiology - Arrhythmias
    Jun 24 2025
    Sinus Bradycardia – Quick Clinical Action GuideInitial EvaluationConfirm ECG diagnosis: Heart rate <60 beats per minute (bpm) at rest.Assess for symptoms: Lightheadedness, syncope.Identify potential causes: High vagal tone (e.g., well-trained athletes), local ischemia, infiltrative disease, hypothyroidism, hypothermia, stroke.Review medication list: Exclude drug effects as an etiology.Assess for sinus pauses: Note if >3 seconds while awake.DiagnosticsElectrocardiography (ECG).Ambulatory ECG Monitoring (Holter): To correlate symptoms with heart rhythm.Event Recorder: If episodes are infrequent, to document rhythm during symptoms.Implantable Loop Recorder: For very infrequent symptoms.Treadmill Testing: To distinguish true chronotropic incompetence (blunted HR response to exercise) from high vagal tone (appropriate HR increase with exercise).Carotid Sinus Massage (CSM): May be useful to establish symptom-rhythm correlation in suspected SA nodal dysfunction.Electrophysiologic (EP) Testing: Usually not necessary in most cases. Reserved for a smaller group of patients in whom the arrhythmia mechanism cannot be determined by noninvasive means.TherapyCorrectable Conditions: Address all correctable conditions (e.g., hypothyroidism) and stop all potentially causative drugs.No specific therapy for asymptomatic patients.Permanent Pacing: Indicated for symptomatic patients.Dual-chamber pacemakers are frequently implanted due to concern of concomitant disease in more distal conduction system, even though a single-chamber atrial pacemaker may suffice.Disposition / ConsultsAdmission: Not explicitly stated for uncomplicated asymptomatic sinus bradycardia, but consider if symptomatic or pauses are significant.Consult Cardiology: For pacemaker implantation in symptomatic patients.Tachycardia Bradycardia Syndrome – Quick Clinical Action GuideInitial EvaluationConfirm presence of sinus or other bradycardia alternating with rapid supraventricular tachycardias (SVTs), most often atrial fibrillation (AF).Assess for symptoms: Lightheadedness, syncope (most often caused by bradycardia or offset pauses).Define offset pause: Duration between termination of AF or atrial flutter and return of sinus rhythm.DiagnosticsElectrocardiography (ECG).Ambulatory ECG Monitoring (Holter).Event Recorder / Implantable Loop Recorder: For symptom-rhythm correlation.TherapyMedical control of rapid arrhythmia: Often limited by worsening bradycardia.Pacemakers: Used to prevent bradycardia.Allow titration of medications to slow conduction through the AV node and prevent episodes of rapid ventricular rate during AF.Disposition / ConsultsConsult Cardiology/Electrophysiology: For management of complex arrhythmias and pacemaker implantation.Sinoatrial Exit Block – Quick Clinical Action GuideInitial EvaluationFirst-degree SA exit block: Cannot be diagnosed on surface EKG as it involves delayed but present conduction.Second-degree SA block: Marked by intermittent block out of the SA node and resultant dropped P waves on EKG.Third-degree SA block (complete sinus arrest): Manifests as complete block of sinus impulses out of the SA node.DiagnosticsElectrocardiography (EKG): To identify dropped P waves (second-degree) or complete sinus arrest (third-degree).Ambulatory ECG Monitoring (Holter).Event Recorder / Implantable Loop Recorder: To correlate symptoms with bradycardia.TherapySymptom alleviation is the principal goal.Asymptomatic patients rarely warrant intervention.Address all correctable conditions and stop all potentially causative drugs.Permanent Pacing: Mainstay of treatment for symptomatic sinus node dysfunction. Dual-chamber pacemakers are frequently implanted.Disposition / ConsultsConsult Cardiology: For pacemaker implantation in symptomatic patients.First-Degree Atrioventricular Block – Quick Clinical Action GuideInitial EvaluationConfirm ECG diagnosis: PR interval on ECG is prolonged (>200 milliseconds), but a preserved 1:1 relationship between atria and ventricles.Identify site of block: Most often in the AV node; absence of BBB or wide QRS makes infra-Hisian block less likely.Assess for symptoms: Rarely symptomatic, but may cause palpitations, cough, dyspnea, chest discomfort, dizziness, or syncope (pacemaker syndrome–like symptoms due to simultaneous atrial and ventricular contraction).Review medication list: Identify AV nodal blocking agents.TherapyRarely warrants treatment.Cessation of nodal blocking agents.Vagolytic maneuvers (e.g., exercise, atropine): Should decrease PR interval if AV node is site of delay. Exacerbation or underlying bundle branch disease may reflect infranodal delay.Permanent Pacing: Only rarely indicated for symptomatic patients with a pacemaker syndrome-like constellation of symptoms.Disposition / ConsultsObservation: For most asymptomatic patients.Second-Degree Atrioventricular Block, Mobitz Type I (Wenckebach) – Quick Clinical Action GuideInitial EvaluationConfirm ECG diagnosis: Gradual prolongation of ...
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    32 mins

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