General Internal Medicine: Perioperative Care, VTE, Delirium and Polypharmacy
Core concepts
General internal medicine integrates perioperative assessment, venous thromboembolism, syncope, delirium, falls and polypharmacy, hypertension, lipid management, screening and evidence-based practice. Perioperative risk depends on patient factors, surgery type and functional capacity. VTE diagnosis uses pretest probability: low or intermediate probability with a negative D-dimer can exclude PE or DVT; high probability needs imaging. Delirium is an acute fluctuating disturbance of attention and cognition; find and treat the cause, including drugs, infection, pain and retention.
Traps
Do not start beta-blockers acutely on the day of surgery to prevent cardiac events; this can cause harm. D-dimer is not useful in high pretest probability and has low specificity in hospitalised, pregnant or older patients. Polypharmacy and anticholinergic burden commonly cause falls and delirium. Syncope with exertion, family history of sudden death or abnormal ECG needs urgent assessment. Always reconcile medicines at admission and discharge.
Worked example / rule of thumb
A 70-year-old has pleuritic chest pain, tachycardia and recent surgery. Wells score is high. Do not rely on D-dimer; arrange CT pulmonary angiography and start anticoagulation if there is no contraindication while awaiting imaging. Rule: D-dimer is a rule-out test only in low or intermediate pretest probability.
Critical Care and Emergency Presentations: Shock, Sepsis, Anaphylaxis and Arrest
Core concepts
Critical care and emergency medicine require a structured ABCDE approach, recognition of shock, sepsis, acute respiratory distress syndrome, airway emergencies, anaphylaxis, poisoning, trauma and cardiac arrest. Differentiate hypovolaemic, cardiogenic, distributive and obstructive shock. Sepsis care includes cultures, broad-spectrum antibiotics, fluids and vasopressors to achieve perfusion targets. Know when to intubate, how to set initial ventilation, and the indications for urgent needle decompression or pericardiocentesis. ACLS emphasises high-quality chest compressions, early defibrillation and reversible-cause review.
Traps
Do not give a fluid bolus to a patient with cardiogenic pulmonary oedema or obstructive shock without treating the cause. In tension pneumothorax, needle decompression is clinical and must not wait for imaging. Anaphylaxis is treated with intramuscular adrenaline, not intravenous antihistamines or steroids alone. In trauma, permissive hypotension may be appropriate until bleeding control. Beware of normal vital signs in young patients with major blood loss.
Worked example / rule of thumb
A patient develops stridor, urticaria and hypotension minutes after an antibiotic. Give intramuscular adrenaline 0.5 mg (1:1000) into the anterolateral thigh, repeat every 5 minutes if needed, call for help, give high-flow oxygen and a rapid fluid bolus. Rule: adrenaline is first-line in anaphylaxis; antihistamines and steroids are adjuncts, not initial treatment.