Internal Medicine and Adult Primary Care
Internal Medicine and Adult Primary Care carries the heaviest clinical weighting: chronic disease control, acute adult presentations, and safe prescribing. Questions test guideline-concordant targets, drug monitoring, and when community management stops being safe.
Core rules
- Hypertension: confirm with repeated seated readings; target <140/90 mmHg generally, <130/80 in diabetes or CKD if tolerated. ACE inhibitor or ARB first-line with albuminuria; never combine ACEi and ARB.
- Type 2 diabetes: metformin first-line; individualize HbA1c around 7% (7.5–8% if frail). At eGFR 30–45 reduce metformin dose; stop below 30. Add SGLT2 inhibitor or GLP-1 receptor agonist when cardiovascular or renal disease is present.
- Acute coronary syndrome: chewed aspirin 300 mg, ECG, troponin; arrange urgent transfer. Thrombolysis is not a primary-care treatment.
- COPD: confirm with spirometry; LABA plus LAMA; systemic steroids only during exacerbations; smoking cessation is the only intervention that changes disease course.
Worked example
A 58-year-old man with type 2 diabetes has eGFR 38 mL/min/1.73 m², urine albumin-to-creatinine ratio 45 mg/mmol, HbA1c 8.1% on metformin 1 g twice daily. Reasoning: metformin needs dose reduction at eGFR 30–45 and withdrawal below 30; his albuminuria justifies an ACE inhibitor or ARB with BP below 130/80; an SGLT2 inhibitor adds renal and cardiovascular protection. Review renal function in 2–4 weeks and refer if eGFR falls more than 25%.
Traps
- Starting aspirin for primary prevention in a low-risk patient.
- Treating a single high blood pressure reading as hypertension.
- Missing painless myocardial infarction in diabetes.
- Continuing metformin during acute illness with dehydration.