Internal Medicine
What OMRSE tests
Internal Medicine questions ask for the next best step in common adult problems: chest pain, dyspnea, diabetes, hypertension, acute kidney injury, anemia, and anticoagulation. The exam rewards problem representation, risk stratification, and safe prescribing more than rare syndromes.
Core rules
- In acute chest pain, obtain a 12-lead ECG within 10 minutes and risk-stratify; do not wait for troponin to treat ST-elevation.
- For diabetes, distinguish acute decompensation from chronic control; check ketones, pH, and potassium when the patient is unwell.
- Before treating anemia, define the pattern (microcytic, normocytic, macrocytic) and check iron studies, B12/folate, and reticulocyte count.
- In AKI, review volume status and nephrotoxins; urgent dialysis is for refractory hyperkalemia, acidosis, pulmonary edema, or uremic complications.
Worked example
A 24-year-old with type 1 diabetes presents with vomiting, glucose 28 mmol/L, pH 7.15, bicarbonate 10 mmol/L, and blood ketones 5 mmol/L. This is diabetic ketoacidosis, not hyperosmolar hyperglycemic state. Start isotonic saline, check potassium, and begin a fixed-rate insulin infusion after fluid resuscitation. Add potassium if K is below 5.2 mmol/L and urine output is present. Do not give bicarbonate unless pH is below 6.9. Continue insulin until ketones clear and the anion gap closes, even if glucose normalizes; add dextrose to the fluids.
Traps that cost marks
- Giving an insulin bolus before fluids in a hypovolemic patient.
- Missing hypokalemia or starting insulin without a potassium result.
- Stopping insulin when glucose reaches normal while ketones persist.
- Treating hyperglycemia without asking about infection, pregnancy, or medication non-adherence.