TM
Internal medicine tips & tricks
for med students, residents,
and junior doctors
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medicine clinical reference cards set
When studying...
IM encompasses the entire medical field, meaning you will be touching on high yield
concepts of ALL systems and illnesses. Be prepared to STUDY HARD.
When studying, compare and contrast between diseases that are commonly tested together.
Notice the similarities and differences between these diseases because that’s how they will
be tested on the Shelf.
For example, knowing the physical exam and diagnostic findings between obstructive
lung diseases and restrictive lung diseases and being able to differentiate from each
other. Both may have similar presentations, but asthmatic patients will improve
significantly after albuterol administration. Knowing these comparisons well will allow
you to predict common test questions.
Make sure you are extremely well studied up on Pulmonary, CVS, and GI, as these subjects
make for the highest portion of questions you will see both in the clinic and on your exam.
Write out different work-ups for common chief complaints. For example, draw out a flow
chart of your differential diagnosis for chest pain. Within this chart, make sure you write out
which tests you would order first and how those tests will help differentiate the possible
diagnoses.
Internal medicine encompasses a lot of questions regarding “what are the next best steps?”
For these questions, think cheap, least invasive, and what will give you the information you
need to confirm your lead differential.
A lot of questions also test on screening guidelines. Be able to understand conditions
associated with when to start screening for certain pathologies, and
what tests to use to do so.
When studying for internal medicine, the absolute number 1 rated textbook
is Step Up to Medicine. This book provides a great overview of the entire
clinical medical sciences you need to know coming out of medical school.
This is also rated as a top 5 resource for Step 2 CK Prep.
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When studying...
Some high yield topics to master early on:
Heart Failures
CAD/Angina/MI
Hypertension
COPD
Acute/Chronic Kidney Injury
Diabetes Mellitus
Anemia
Acid-Base Disturbances
UTI
It is very important to know these topics like the back
of your hand. That being said, in the clinic, it can be
hard to make decisions on diagnosis and
management. The following cards from my IM
Reference Cards Set encompass a lot of these
conditions and provide you with the most important
information to know in the field regarding them.
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medicine clinical reference cards set
before your IM rotation
Once you receive onboarding information, feel free to reach out to the physician/resident
beforehand. Let them know who you are and that you will be joining them for the next X weeks. Keep
the message short though, do not try to say too much; just be genuine.
Email is the most professional outlet to do so, but reaching out via cell phone is also widely
accepted nowadays
Practitionet is a program you can look into for assistance with reaching out and getting
connected
Once you have your schedule, check the list of cases for your week so you can read about them in
advance. If you do this, then you can:
Read up on the basic science and interventions regarding the diseases.
Understand any possible implications, next steps in management and more
Know what to look for when you examine the patient. This does not only include what is typical
for different diseases, but what may also be irregular presentations of the same diseases.
Some skills to be weary of acquiring:
IM is all about developing your diagnostic abilities. Here
is how you can best exercise that:
During the conversation with the patient, focus on the
medical history they provide you with. Start with the
main complaints (max 3) and then narrow down your
differentials.
Try to keep a maximum of three conditions in your
mind to avoid anchoring. Once finished, differentiate
between those three conditions by proceeding with
the elements of the physical exam relevant to them.
When done with the conversation, develop your
management plan. Develop your plan in the sense
that you are able to completely explain what is part of
this plan, and why.
Read Chest X-rays.
Read EKGs.
We recommend studying up on our EKGs section of our
cardiology guide to prepare you with the necessary
foundation to interpret EKGs when in the field.
Additionally, to help you with EKG interpretation in the
field, we have a card you can reference to assist you!
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medicine clinical reference cards set
during your IM rotation
Understand your intention with this rotation.
Are you interested in specializing in internal medicine? Perfect! Use this as the opportunity to
really dive in, learn, make connections, and get better at your craft. See as many cases as you can,
ask to practice techniques, etc.
Not sure if you are interested in internal medicine? That’s fine! That is the whole point of the
rotation. Use this time to dive in and really get your full experience. That way you can walk away
from your rotation as knowing you for sure want to do surgery, or for sure do not.
No interest in internal medicine at all? Again, totally fine. But, keep this in mind: you have the
next X weeks to have your experience in internal medicine for potentially the rest of your life. Live
your experience to the fullest, and still be eager to learn as you can transfer a lot of your lessons
from internal medicine into other rotations and specialties. Also, internal medicine sets up a big
foundation of knowledge for ALL other specialties, and so it is definitely important to make the
most of this rotation.
Also keep in mind that your preceptor’s evaluation is still something that residency programs
will see. It is still important to work hard and make a good impression.
Pre round early.
Get the sign-out from the overnight resident (night float). If you don’t understand why they
did something, ASK! You're attending will likely ask you on rounds especially if the rationale
is unclear.
Look at vitals, Is and Os, imaging and labs
Record lab values. Write them down and have them readily available when presenting the
case. Do not only have the current alb values, but have their trends (how has this value
changed over night?)
Ask the nurses how the patient did over night and if you can go see them.
Have a flow for presenting cases and make sure it’s succinct.
Start jotting down your next steps in management.
Create a rough personal note for yourself. This should include:
Symptom
Diagnosis
Explanation for why the top diagnosis is most likely.
Correlation between differentials and patient presentation.
Consolidate possible causes.
Next steps for testing.
Plan
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medicine clinical reference cards set
during your IM rotation
When you are writing up your full note, remember to follow the
SOAP format.
Subjective - History
Objective - Vitals, PE, Observations, Tests to Order
When documenting exams, there are some important
things you should be commenting on based on the
system. Use my Physical Exam Card to reference what
the normal exams should look like for each system. If
there is a deviation in your patient, make sure you discuss
that in your note. This should still be done concisely.
Assessment - Review of presentation and tests
Plan - What is the management plan?
When pre-rounding:
Do not hesitate to notify your resident/physician if you
suspect something is wrong.
If a patient asks you to come back later, this is fine,
only IF they are stable.
When rounding with the physician, esure that you have examination gloves ready for either the
preceptor (for when he/she asks for some) or for yourself (for when the preceptor asks for you to check
something out).
Ask questions! As much as physicians will pimp you out, it is also okay for you to ask questions. This
shows them that you are here to learn. It is always better to look like an open learner rather than a know-
it-all; trust me, what you think you know, the physician knows 100 times more.
That being said, it is important to know WHEN to ask questions. If the physician is in the middle of
talking to the patient, maybe don’t ask your question then and there. Especially in situations where
things may not be going as planned. Be able to read the room and understand when the
atmosphere is a bit more laid back and when it is appropriate to ask your question.
The nurses and other members of the healthcare team are resources for you too. Do not just rely on the
physician for a bulk of your learning. Don’t shy away from asking the techs and nurses any questions you
may have.
Day 1, make sure to introduce yourself to all the nurses you will be working with as that goes a long way!
Click or scan here to get the internal TM
medicine clinical reference cards set
during your IM rotation
Help the residents! They’ll greatly appreciate any effort you can make to help alleviate
their load. This is also something they will consider when evaluating you.
When you get a new patient who had an H&P done overnight. Do NOT assume it was
done correctly. Verify the history by asking your own set of questions to the patient. If
there are discrepancies, make sure to include that in your note.
If you’re not sure what is keeping your patient in the hospital, ASK. Barriers to discharge
need to be addressed sooner than later and you always want to bring up discharge
planning as you wrap up your presentation (if the patient is stable and almost ready to
go home).
Documentation:
Keep your note concise and to the point. Do not leave out IMPORTANT
information.
When your plan includes medications- note the dose, duration, and route of intake
NEVER write “today” or “tomorrow” without adding a date next to it.
When labeling diagnoses, be specific with the exact classification. For example, if
the patient has a UTI, what is the infectious pathogen?
Look at your residents notes and copy their format! This will also help you with
wording, the more medical notes you read, the easier it is to word things. Ask for
permission first of course.
If you see a very unique/interesting case during your time rotating, ask your preceptor if
you can potentially write it up. This is a great chance for you to get published!
Ask your preceptor for feedback. There is always room to improve so be willing to ask
and receive feedback. Now, learn from this and implement the feedback.
Useful apps to use while you are in clinic:
Hospitalist Handbook helps you quickly learn how to approach different diseases
or conditions that are common in the hospital setting.
Epocrates helps get you clinical decision support, and saves time with prescribing.
This not only helps with choosing medications, but also with dosing.
MDCalc is a free app that allows you to calculate different risk/score calculations.
UpToDate helps you find the most up-to-date information in medicine regarding
diagnoses, management, and treatment.
Click or scan here to get the internal TM
medicine clinical reference cards set
during your IM rotation
When you are done with your day at the
hospital:
1. Finalize all your notes for the day before giving
it off to the residents and physician
2. Feel free to go in and check in on your patients
and talk to their family members with updates
3. Work on discharge summaries
4. Ask your residents/physicians if there is
anything else you can do to help
5. Use the IPASS framework for signing off
patients over to the night team found in my
Reference cards!
after your IM rotation
Consider leaving a thank you note for the physician on your last day. If possible, even a
thoughtful little gift (ex. Their favorite candy, etc.). Physicians really appreciate knowing
that you took something away from their rotation and so showing that gratitude goes
miles. Seeing that you even took the time to write out a note over texting/emailing them
also shows them how thoughtful you are.
If this is the field you want to pursue, definitely try to maintain a long term relationship
with this physician. Write a follow up letter 2 weeks after your rotation has ended. Talk
about what the experience meant to you. Let them know you appreciated their
mentorship and would be happy to work together in the future in some medium.
Maybe even set up some further shadowing.
Even if you do not want to match IM, having an LOR from IM is something residency’s
love to see. If you want a LOR from your attending, ask BEFORE the rotation is over.
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