Internal Medicine: Common Adult Presentations and Emergencies
Internal Medicine: what is tested
Internal medicine tests the diagnosis and management of common adult presentations: chest pain, breathlessness, hypertension, diabetes, acute kidney injury, cirrhosis and thyroid disease. The exam emphasises initial investigation and safe first-line treatment.
Core rules
- Acute coronary syndrome: ECG within 10 minutes and troponin. ST-elevation myocardial infarction needs urgent reperfusion; aspirin and a P2Y12 inhibitor are given unless contraindicated.
- Heart failure with reduced ejection fraction: loop diuretic for congestion plus disease-modifying therapy such as an ACE inhibitor or ARNI, beta-blocker and mineralocorticoid receptor antagonist.
- Diabetes: metformin is first-line unless contraindicated; assess HbA1c, renal function and cardiovascular risk. Hypoglycaemia is treated with fast-acting glucose, then longer-acting carbohydrate.
- Acute kidney injury: check volume status, urinalysis, electrolytes and medications; stop nephrotoxins and treat obstruction or sepsis. Hyperkalaemia with ECG changes needs intravenous calcium first.
Worked example. A 22-year-old with type 1 diabetes has vomiting, abdominal pain, glucose 28 mmol/L, pH 7.15, bicarbonate 10 mmol/L and ketonuria. Reasoning: diabetic ketoacidosis. Start isotonic saline first, check potassium, and begin insulin infusion once potassium is above 3.3 mmol/L; replace potassium as needed. Bicarbonate is not routine and is reserved for severe acidaemia such as pH below 6.9. Look for infection or missed insulin as the precipitant.
Traps that cost marks
- Starting insulin before fluid resuscitation and potassium assessment.
- Giving routine bicarbonate in diabetic ketoacidosis.
- Treating hyperkalaemia with ECG changes using insulin before intravenous calcium.
- Missing silent myocardial infarction in diabetes or the elderly.