General Internal Medicine: Structured Assessment and Guideline-Concordant Management
General Internal Medicine tests the candidate’s ability to manage undifferentiated adult presentations and common chronic disease in a whole-patient context. It rewards structured problem representation, severity scoring and guideline-concordant decisions rather than rare diagnoses.
Core rules
- Build a problem list from the history and examination, then rank causes by probability and harm; document what would change management.
- Use validated severity tools for common acute presentations: CURB-65 for community-acquired pneumonia, Wells or PERC for pulmonary embolism, and NEWS2 for deterioration.
- Treat chronic disease to individualized targets: most adults with hypertension to <130/80 mmHg if tolerated; HbA1c individualized, commonly 7–8% in multimorbidity.
- Adjust every drug for renal function and interactions; stop NSAIDs in CKD, heart failure and dehydration.
- Use diagnostic stewardship: order tests only when the result will alter treatment.
Worked example
A 72-year-old man has fever, productive cough and new confusion. RR 24/min, BP 110/70 mmHg, urea 9 mmol/L. CURB-65: confusion 1, urea >7 1, RR <30 0, BP not low 0, age ≥65 1 - total 3. This is high-risk pneumonia: admit, obtain blood cultures and sputum where possible, start empirical antibiotics within 4 hours, give oxygen to target saturation 94–98% (88–92% if COPD), and reassess fluids and sepsis criteria.
Traps
- Using qSOFA as a stand-alone sepsis rule; it is a risk-stratification adjunct, not a diagnostic test.
- Treating the chest X-ray rather than the patient: pneumonia can be diagnosed clinically in the right setting.
- Missing renal dosing of antibiotics and anticoagulants.