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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 68-year-old male with a known history of severe COPD presents with increased dyspnea, productive cough with purulent sputum, and increased wheezing for the past 2 days. He is afebrile. His vital signs are HR 105 bpm, RR 28 bpm, and O2 saturation 88% on room air. An arterial blood gas (ABG) analysis shows: pH 7.28, PaCO2 70 mmHg, PaO2 55 mmHg, HCO3 30 mEq/L. What is the most appropriate initial management for his respiratory status?

A) Intravenous corticosteroids

B) Endotracheal intubation and mechanical ventilation

C) High-flow oxygen via a non-rebreather mask

D) Non-invasive positive pressure ventilation (NIV)

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Question 2

A 45-year-old male presents to the emergency department with a 6-hour history of multiple episodes of hematemesis and melena. He reports occasional NSAID use for back pain. On examination, he is pale and lethargic. Vital signs: BP 90/60 mmHg, HR 110 bpm, RR 20 bpm, O2 saturation 96%. His hemoglobin is 8.5 g/dL. What is the immediate priority in the management of this patient?

A) Type and crossmatch for blood transfusion and immediate transfusion of packed red blood cells

B) Initiation of crystalloid intravenous fluids and hemodynamic stabilization

C) Urgent upper gastrointestinal endoscopy

D) Administration of intravenous proton pump inhibitors (PPIs)

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Question 3

A 68-year-old male with a history of Type 2 Diabetes Mellitus, hypertension, and osteoarthritis presents with increasing fatigue, leg swelling, and decreased urine output over the past week. His medications include Metformin, Lisinopril, and Ibuprofen as needed for joint pain. Laboratory results show serum creatinine 3.5 mg/dL (baseline 1.2 mg/dL), BUN 60 mg/dL, and urine output of 300 mL/24 hours. Urinalysis shows trace protein and no cells or casts. What is the most likely cause of his acute kidney injury (AKI)?

A) Post-renal obstruction

B) Acute Tubular Necrosis (ATN)

C) Acute Glomerulonephritis

D) Prerenal Azotemia

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