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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 50-pack-year smoking history and a known diagnosis of COPD presents to the emergency department with worsening dyspnea, increased cough, and production of purulent sputum over the past 3 days. His oxygen saturation is 88% on room air, respiratory rate is 26 breaths/min, and he is using accessory muscles of respiration. Auscultation of the lungs reveals diffuse inspiratory and expiratory wheezes with prolonged expiration. What is the MOST appropriate initial pharmacological management for this patient's acute exacerbation?

A) Initiation of systemic oral corticosteroids.

B) Administration of a short-acting inhaled bronchodilator.

C) Immediate intubation and mechanical ventilation.

D) Start broad-spectrum intravenous antibiotics.

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Question 2

A 70-year-old female is brought to the emergency department with a 2-day history of fever, chills, productive cough, and increasing confusion. Her vital signs are: BP 80/50 mmHg, HR 120 bpm, RR 28 breaths/min, Temp 39.5°C, SpO2 92% on room air. Physical exam reveals crackles and dullness to percussion in the right lower lung field.

A) Order a stat chest X-ray and arterial blood gas.

B) Administer broad-spectrum intravenous antibiotics immediately after obtaining blood cultures.

C) Initiate a norepinephrine infusion to raise blood pressure.

D) Perform endotracheal intubation for airway protection.

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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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