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Master Internal Medicine
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HIGH YIELD NOTES ~5 min read

Core Concepts

Internal Medicine is the specialty dedicated to the prevention, diagnosis, and non-surgical treatment of adult diseases, often involving multiple organ systems. It emphasizes a comprehensive, evidence-based approach to patient care, focusing on chronic disease management, acute exacerbations, and the complexities of comorbidities. Core areas include cardiovascular, pulmonary, renal, gastrointestinal, endocrine, rheumatologic, hematologic, and infectious diseases. A strong understanding of pathophysiology and the interconnectedness of organ systems is crucial.

Clinical Presentation

**Cardiovascular:** Chest pain (angina, MI), dyspnea (HF), palpitations, syncope, peripheral edema.
**Pulmonary:** Dyspnea (acute/chronic), cough, hemoptysis, pleuritic chest pain.
**Gastrointestinal:** Abdominal pain, nausea/vomiting, altered bowel habits, jaundice, GI bleeding (hematemesis, melena, hematochezia).
**Renal/Electrolyte:** Oliguria/anuria, edema, flank pain, altered mental status (uremia, severe electrolyte imbalance).
**Endocrine:** Polyuria/polydipsia/polyphagia (DM), weight changes, fatigue, heat/cold intolerance (thyroid), specific neurological signs (hypoglycemia).
**Infectious:** Fever, chills, malaise, localized signs of infection, altered mental status (sepsis).
**Rheumatologic:** Joint pain/swelling (mono/polyarticular), morning stiffness, systemic symptoms (fatigue, fever, rash).
**Hematologic:** Pallor, fatigue, easy bruising/bleeding, lymphadenopathy.
**General/Systemic:** Unexplained fatigue, weight loss/gain, unexplained fever, altered mental status, generalized weakness.

Diagnosis (Gold Standard)

A thorough history and physical examination are always the first and most critical steps.

**Cardiovascular:** ECG (MI, arrhythmias), Echocardiography (HF, valvular disease), Cardiac biomarkers (MI), CT Angiography (PE), Coronary Angiography (CAD).
**Pulmonary:** Chest X-ray/CT (pneumonia, PE, malignancy), PFTs (asthma, COPD), ABG (respiratory failure).
**Gastrointestinal:** Endoscopy (UGI bleed, PUD, IBD), Colonoscopy (LGI bleed, IBD), Abdominal CT/MRI (pancreatitis, liver disease).
**Renal:** Serum creatinine/eGFR (CKD, AKI), Urinalysis (hematuria, proteinuria, infection), Renal ultrasound (obstruction).
**Endocrine:** HbA1c, FBG (DM), TSH/Free T4 (thyroid), ACTH stimulation test (adrenal insufficiency).
**Infectious:** Blood cultures, specific cultures (urine, sputum, CSF), PCR testing, serology.
**Rheumatologic:** Autoantibody panels (ANA, RF, anti-CCP), ESR/CRP.
**Hematologic:** CBC (anemia, leukemias), Peripheral blood smear, Coagulation panel (PT/aPTT/INR).

Management (First Line)

**Acute Cardiovascular:** Aspirin, nitrates, beta-blockers, ACEi/ARBs (MI, HF); diuretics (HF); anticoagulation (Afib, PE); reperfusion (MI).
**Chronic Cardiovascular:** Lifestyle modification, statins (dyslipidemia), anti-hypertensives (HTN), antiplatelets (CAD).
**Pulmonary:** Bronchodilators (SABA/LABA), inhaled corticosteroids (asthma, COPD), antibiotics (pneumonia), oxygen support (respiratory failure), anticoagulation (PE).
**Gastrointestinal:** PPIs (PUD, GERD); immunosuppressants (IBD); IVF, bowel rest (pancreatitis, diverticulitis).
**Renal/Electrolyte:** Fluid management, electrolyte replacement/restriction, diuretics, dialysis (AKI, severe CKD).
**Endocrine:** Metformin, SGLT2i, GLP1-RA (DM Type 2); insulin (DM Type 1, severe hyperglycemia); levothyroxine (hypothyroidism); glucocorticoids (adrenal insufficiency).
**Infectious:** Empiric broad-spectrum antibiotics, then targeted therapy; source control; antiviral/antifungal as indicated.
**Rheumatologic:** NSAIDs, corticosteroids (acute flares); DMARDs (methotrexate, biologics for RA, SLE).
**General:** Symptomatic relief, patient education, lifestyle modifications, multidisciplinary team involvement.

Exam Red Flags

**Sepsis:** Any infection with end-organ dysfunction (qSOFA ≥2). Initiate broad-spectrum antibiotics and fluids within 1 hour.
**Acute Coronary Syndrome (ACS):** New/worsening chest pain, ECG changes, elevated troponins. Urgent reperfusion for STEMI.
**Pulmonary Embolism (PE):** Acute dyspnea, pleuritic chest pain, tachycardia, hypoxia. High suspicion with risk factors. Anticoagulate immediately.
**Diabetic Ketoacidosis (DKA)/Hyperosmolar Hyperglycemic State (HHS):** Severe hyperglycemia with metabolic acidosis (DKA) or extreme dehydration (HHS). Aggressive fluid resuscitation, insulin, electrolyte correction.
**GI Bleed:** Hematemesis, melena, hematochezia, hemodynamic instability. ABCs, fluid resuscitation, consider endoscopy.
**Altered Mental Status:** Rule out hypoglycemia, hypoxia, sepsis, stroke, intoxication, electrolyte imbalance, uremia, liver encephalopathy.
**Acute Kidney Injury (AKI):** Rapid rise in creatinine. Differentiate pre-renal, intrinsic, post-renal. Address underlying cause.
**Hypertensive Emergency:** Severe HTN with acute target organ damage (e.g., encephalopathy, pulmonary edema). Requires immediate IV antihypertensives.
**Anaphylaxis:** Rapid onset allergic reaction with airway compromise, hypotension. Administer IM epinephrine immediately.

Sample Practice Questions

Question 1

A 72-year-old male with a history of chronic kidney disease (CKD) stage 4, hypertension, and heart failure presents with a 2-day history of increasing generalized weakness, fatigue, and palpitations. His current medications include lisinopril, spironolactone, and furosemide. An ECG performed in the emergency department shows tall, peaked T waves in several leads. Laboratory results reveal a serum potassium level of 6.9 mEq/L, creatinine 3.5 mg/dL, and BUN 80 mg/dL. Which of the following interventions should be administered MOST immediately to stabilize the cardiac membrane?

A) Intravenous insulin and dextrose.

B) Intravenous calcium gluconate.

C) Nebulized albuterol.

D) Oral sodium polystyrene sulfonate.

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Question 2

A 45-year-old male presents with sudden onset of severe right upper quadrant pain that radiates to his right shoulder. He also reports nausea, vomiting, and fever (38.5°C). On examination, he has tenderness and guarding in the right upper quadrant with a positive Murphy's sign. Laboratory tests reveal leukocytosis (WBC 16,000/µL) and mildly elevated alkaline phosphatase. Liver enzymes and bilirubin are within normal limits. An ultrasound shows gallstones and gallbladder wall thickening with pericholecystic fluid. What is the most appropriate initial management for this patient?

A) Prescribe oral antibiotics and send home with dietary recommendations.

B) Initiate broad-spectrum IV antibiotics, IV fluids, and analgesia, with surgical consultation for cholecystectomy.

C) Perform an Endoscopic Retrograde Cholangiopancreatography (ERCP) immediately.

D) Administer ursodeoxycholic acid to dissolve the gallstones.

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Question 3

A 55-year-old male presents to the ER with severe retrosternal chest pain radiating to his left arm, associated with dyspnea and diaphoresis, ongoing for 30 minutes. His ECG shows ST-segment elevations in leads II, III, and aVF. Blood pressure is 100/60 mmHg, heart rate 98 bpm.

A) Administer intravenous nitroglycerin and morphine.

B) Prepare for immediate percutaneous coronary intervention (PCI).

C) Administer oral aspirin 325 mg and clopidogrel 300 mg.

D) Initiate a continuous intravenous beta-blocker infusion.

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