General Internal Medicine
Core concepts
Integrate multisystem disease: approach to the patient with fatigue, weight loss, fever of unknown origin, and syncope. Understand the principles of perioperative risk assessment, polypharmacy, and the rational use of investigations. Be familiar with hypertension, dyslipidaemia, and preventive care, and with the recognition of common presentations such as chest pain, dyspnoea, and abdominal pain. Know how to structure a differential diagnosis and prioritise investigations.
Traps
Questions test anchoring bias - a single diagnosis may not explain all findings. Distinguish syncope (transient loss of consciousness with rapid recovery) from seizure and from psychogenic causes. In weight loss, do not miss malignancy, TB, diabetes, and hyperthyroidism. In hypertension, confirm with ambulatory monitoring and screen for secondary causes when features suggest them.
Rule of thumb
For any undifferentiated presentation, structure the differential by systems and by time course, and let the history and examination direct the investigations rather than ordering a broad panel indiscriminately.
Worked example
An older patient with recurrent syncope: take a careful history for prodrome, triggers, and injury; perform ECG and orthostatic BP; consider Holter or loop recorder if cardiac syncope is suspected.
Geriatrics and Perioperative Care
Core concepts
Understand the geriatric giants: falls, immobility, incontinence, cognitive impairment, and polypharmacy. Use comprehensive geriatric assessment and deprescribing principles. Know the physiology of ageing and how it alters drug handling and fluid balance. In perioperative care, understand risk stratification (cardiac risk indices, functional capacity), the value of frailty assessment, and the management of delirium and postoperative complications.
Traps
Questions test delirium versus dementia - delirium is acute, fluctuating, with altered attention; dementia is chronic and progressive. Do not attribute falls to ageing alone; look for medication causes, arrhythmia, and vision problems. In perioperative risk, remember that functional capacity (ability to climb stairs) is a strong predictor. Avoid benzodiazepines and anticholinergics in older adults where possible.
Rule of thumb
In an older patient with an acute change in behaviour, look for the causes of delirium (infection, drugs, pain, constipation, retention, hypoxia, electrolyte disturbance) and treat the cause rather than sedating.
Worked example
An older patient with a hip fracture and new confusion: screen for infection, review medications, correct electrolytes, and use non-pharmacological measures first; reserve antipsychotics for severe distress.