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Internal Medicine Housemanship - Complete Synopsis

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1. The Mindset & Role of a House Officer

• Clerking new admissions (full history + examination + initial plan)
• Executing the ward management plan under senior supervision
• Monitoring patients and flagging deterioration early
• Documenting accurately and completely at every step
• Learning continuously from every patient encounter

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2. Daily Ward Routine

Pre-round (6:00 - 7:30 AM)

• Review all patients: past medical history, vitals overnight, I&O charts, new blood results, imaging
• Compile a team list (patient name, diagnosis, active issues, pending results, plan)
• Flag sick patients for urgent senior review

Morning Ward Rounds (8:00 AM onwards)

• Present new cases: presenting complaint, background, examination findings, investigations, impression, initial plan
• Present old cases: overnight events, new results, new complaints, plan for the day
• Document all decisions in SOAP format:
  • S - Subjective (patient complaints, overnight events)
  • O - Objective (vitals, exam findings, new results)
  • A - Assessment (current status, diagnosis)
  • P - Plan (medications, investigations, referrals, discharge)

Post-round Changes (Prioritize!)

1. Urgent - things the senior says to do NOW (urgent scans, urgent labs, calling for critical results)
2. Referrals and discharges - done before lunch
3. Passive/non-urgent changes - trace results, write prescriptions, complete paperwork

Exit Rounds / Evening Review

• Review sick patients
• Handover to on-call colleague (flag unstable patients, pending results, expected events)

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3. Clerking a Patient (Admission Write-up)

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4. Core Clinical Skills to Master

Basic Procedural Skills (Mandatory)

• Venipuncture - blood taking (FBC, RFT, LFT, coagulation, cultures)
• IV cannula insertion - peripheral line setup
• ABG (Arterial Blood Gas) - radial artery puncture, immediate interpretation
• Blood cultures - two sets, aseptic technique
• ECG acquisition and interpretation - 12-lead; recognize common patterns
• Urinalysis - dipstick interpretation
• Blood glucose (glucometer)
• Urinary catheterization - male and female
• BP measurement - correct cuff size, both arms where relevant
• Fundoscopy - hypertensive/diabetic changes

Key Investigations to Order and Interpret

ABG Interpretation - Stepwise

1. pH: <7.35 = acidosis; >7.45 = alkalosis
2. PaCO₂: ↑ in respiratory acidosis; ↓ in respiratory alkalosis
3. HCO₃⁻: ↓ in metabolic acidosis; ↑ in metabolic alkalosis
4. Compensation: check if appropriate
5. Oxygenation: PaO₂ and A-a gradient

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5. Common Conditions You Must Know in Internal Medicine

Cardiovascular

• Acute coronary syndrome (ACS) - STEMI/NSTEMI/UA: MONA (Morphine, O₂, Nitrates, Aspirin), antiplatelet therapy, urgent cardiology referral
• Heart failure - classification (HFrEF vs HFpEF), diuresis, fluid balance
• Hypertensive emergency - BP targets, IV labetalol/nicardipine, end-organ damage assessment
• Atrial fibrillation - rate vs rhythm control, anticoagulation, CHADS₂-VASc score

Respiratory

• Community-acquired pneumonia (CAP) - CURB-65 score, antibiotics (amoxicillin ± macrolide)
• COPD exacerbation - controlled oxygen (target SpO₂ 88-92%), bronchodilators, steroids, antibiotics
• Asthma attack - severity assessment, SABA, IV magnesium in severe attack
• Pulmonary embolism - Wells score, CTPA, anticoagulation, thrombolysis if massive

Gastroenterology

• Upper GI bleed - Glasgow-Blatchford score, resuscitation, PPI infusion, endoscopy
• Acute hepatitis - viral, drug-induced, autoimmune
• Acute pancreatitis - modified Glasgow/Ranson criteria, aggressive fluids, NBM, analgesia
• Liver cirrhosis complications - ascites, SBP, hepatic encephalopathy, variceal bleed

Nephrology

• AKI - KDIGO staging, prerenal vs intrinsic vs postrenal, fluid challenge, nephrology consult
• CKD - progression, anaemia of CKD, hyperphosphataemia, indications for dialysis
• Electrolyte emergencies - hyperkalaemia (ECG changes, calcium gluconate, insulin-dextrose, kayexalate)

Endocrinology/Metabolic

• Diabetic ketoacidosis (DKA) - fluid resuscitation, fixed-rate insulin infusion, K⁺ replacement
• Hyperosmolar hyperglycaemic state (HHS) - slow fluid correction, anticoagulation
• Hypoglycaemia - 15-15 rule, IV dextrose if unconscious
• Thyroid emergencies - thyroid storm, myxoedema coma

Neurology

• Stroke - FAST, CT head immediately, thrombolysis within 4.5 hours if ischaemic, BP management
• Seizure - benzodiazepines first-line, exclude metabolic causes, AED loading if status epilepticus
• Altered consciousness - AEIOU-TIPS mnemonic

Infectious Disease / Sepsis

• Sepsis (Sepsis-3) - SOFA score, quick SOFA (qSOFA: RR ≥22, AMS, SBP ≤100)
• Sepsis bundle (Hour-1):
  • Blood cultures x2 before antibiotics
  • Broad-spectrum IV antibiotics within 1 hour
  • 30 mL/kg IV crystalloid for hypotension
  • Lactate measurement
  • Vasopressors if MAP <65 mmHg despite fluids
• Common antibiotic empirical regimens - know your hospital's antibiogram

Haematology

• Anaemia workup - microcytic (iron studies), normocytic (reticulocytes), macrocytic (B12/folate)
• DVT/PE - anticoagulation, DOAC vs LMWH
• Thrombocytopenia - causes: ITP, HIT, TTP/HUS, marrow failure

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6. Medical Emergencies - Know These Cold

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7. Documentation Rules

• SOAP format for every ward round entry
• Date, time, designation, legible signature on every entry
• Medication prescriptions - drug name (generic), dose, route, frequency, duration, indication
• Incident reports - any adverse event, needle-stick injury, medication error
• Discharge summaries - diagnosis, hospital course, medications on discharge, follow-up
• Consent - informed consent before any procedure; document the discussion
• Death certification - cause of death, immediate and underlying; know the difference between medical and coroner's cases

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8. Communication Essentials

Presenting on Rounds

• New patient: PC, brief HPI, PMH, key exam findings, key investigations, impression, plan
• Old patient: events overnight, new results, current status, today's plan
• Be concise - 2 minutes maximum per patient

Requesting Investigations / Referrals

• Know the indication before you call
• Provide: patient name, age, bed number, working diagnosis, specific question for the specialist
• Use ISBAR for handovers:
  • I - Identify (yourself and patient)
  • S - Situation (what is the problem now)
  • B - Background (relevant history)
  • A - Assessment (your clinical impression)
  • R - Recommendation (what you want done)

Handover

• Highlight: sick patients, pending results that may change management, expected events
• Give clear instructions on what action to take if specific events occur

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9. Prescribing Safety

• Always check allergy status before prescribing
• Know common drug interactions (warfarin, digoxin, lithium are notorious)
• Renal dosing - adjust doses for AKI/CKD (gentamicin, vancomycin, metformin, NSAIDs are high risk)
• NSAID caution - avoid in AKI, peptic ulcer disease, CCF
• Anticoagulants - know reversal agents: Vitamin K/FFP/PCC for warfarin; andexanet alfa for apixaban/rivaroxaban; idarucizumab for dabigatran
• Electrolyte replacement - oral preferred; IV potassium never faster than 20 mmol/hr peripherally

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10. Professionalism & Self-Care

• Show up on time - your team and patients depend on it
• Know your limits - escalate early; calling for help is not weakness
• Universal precautions - gloves, mask, handwashing; needle-stick protocol
• Patient confidentiality - never discuss cases outside clinical context
• Consent and autonomy - document; patient has the right to refuse
• Mental health - housemanship is the hardest year; recognize burnout; use available support

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11. Quick Reference - High-Yield Scores to Know

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Summary: The 10 Things to Nail from Day 1

1. Know your patients before every round - read the notes the night before
2. Systematic clerking - never skip a section
3. Interpret basic investigations yourself - ECG, ABG, CXR, FBC, RFT
4. Know the sepsis bundle - time-sensitive; seconds matter
5. Prescribe safely - check allergy, renal function, and interactions every time
6. Document everything - if it's not written, it didn't happen
7. Escalate early - call your registrar before the patient crashes
8. Master ISBAR handover - clear, structured, no ambiguity
9. Prioritize tasks after rounds - urgent before routine
10. Know the emergencies cold - cardiac arrest, anaphylaxis, DKA, hyperkalaemia, status epilepticus

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