General Internal Medicine
Core concepts
This domain rewards a systematic approach to the undifferentiated patient: history and physical, problem representation, and prioritized differential diagnosis. Know the perioperative risk assessment framework (cardiac risk indices, functional capacity, when to delay surgery), the approach to syncope (reflex, orthostatic, cardiac), and the management of common inpatient problems - delirium, falls, pressure ulcers, and polypharmacy. Understand the principles of preoperative optimization, the interpretation of common laboratory abnormalities, and the safe prescribing of anticoagulants and insulin in the hospital.
Traps
Examiners test the difference between syncope (transient loss of consciousness with rapid recovery) and seizure, and the fact that cardiac syncope carries the highest mortality and warrants investigation. Beware of attributing symptoms to "age" without a workup, and of missing drug interactions in polypharmacy. Remember that perioperative beta-blockers should not be started on the day of surgery (risk of stroke and hypotension).
Worked rule of thumb
Syncope workup: history and examination first, then ECG. Red flags for cardiac cause include syncope during exertion, no prodrome, family history of sudden death, and abnormal ECG - these warrant admission and monitoring.
Key points
- Cardiac syncope has the highest mortality and needs investigation.
- Do not attribute symptoms to age without evaluation.
- Review medications for interactions and anticholinergic burden.
- Do not start beta-blockers on the day of surgery.
- Functional capacity guides perioperative risk.