What are the basic guidelines for managing common internal medicine conditions?

Basic Guidelines for Managing Common Internal Medicine Conditions

The management of common internal medicine conditions should follow a patient-centered approach that addresses multimorbidity and polypharmacy through systematic assessment, shared decision-making, individualized treatment plans, and structured follow-up to optimize outcomes and quality of life. 1

Identification of Patients Requiring Comprehensive Management

• Identify patients with multimorbidity at risk of adverse events (e.g., unplanned hospital admission) using prognostic models either opportunistically during routine care or through systematic screening 1
• Pay particular attention to patients with multiple conditions who take multiple medications (polypharmacy), as they face increased complexity in care management 1
• Consider patients with chronic multisymptom illness (CMI) who may present with multiple poorly understood symptoms across different body systems 1

Comprehensive Assessment

Medical History and Clinical Evaluation

• Conduct thorough assessment of interacting conditions and treatments, including complete medical history and clinical evaluation 1
• Document all known diagnoses, conditions, existing laboratory results, and medication-related problems in the electronic medical record 2
• Assess physiological and functional status, including nutritional and hydration requirements 2
• Evaluate for common comorbidities such as chronic pain, depression, and anxiety 2

Medication Review

• Create an accurate medication list including all prescriptions, over-the-counter medications, supplements, and herbal remedies 2
• Use validated tools like Beers Criteria or STOPP/START to identify potentially inappropriate medications in older adults 2
• Evaluate potential drug-drug interactions using interaction databases, with particular attention to QT prolongation risks, anticoagulant interactions, and serotonin syndrome potential 2
• Identify medications that may worsen existing conditions (drug-disease interactions), such as NSAIDs in heart failure, chronic kidney disease, or hypertension 2

Patient Preferences and Goal Setting

• Elicit patient preferences and expectations regarding their care 1
• Engage in shared decision-making with patients about treatment options and level of involvement 1
• Discuss with patients the purpose of medication optimization to improve quality of life and function 2
• Encourage patients to express their personal values, aims, and priorities regarding treatment 2

Individualized Management

Treatment Optimization

• Apply guiding principles that optimize treatment benefits over possible harms 1
• Consider cognitive-behavioral therapy and mindfulness-based treatments for patients with chronic multisymptom illness 1
• Consider exercise for patients with symptoms consistent with fibromyalgia syndrome 1
• Target medications from which patients no longer derive reasonable benefit for potential deprescribing 2
• Consider deprescribing when potential harm outweighs benefit, including education about risks for patients and families 2

Care Planning and Communication

• Develop care plans that address ongoing medical and social care needs while focusing on enhancing social connectedness and community involvement 1
• Use an individualized patient-held medication plan that includes specific information on drugs and instructions for usage 1
• Ensure ongoing and adequate communication, particularly around medicines and wider care plans 1
• Document practice guidelines clearly, including standardized referral data, diagnosis protocols, baseline assessments, and therapeutic algorithms 1

Monitoring and Follow-up

• Review and update medication/care plans regularly to recognize and record changes in needs 1
• Schedule regular follow-up appointments to assess medication effectiveness and adverse effects 2
• Monitor treatment effects and clinical parameters, as well as side effects at follow-up appointments 1
• Increase monitoring frequency during care transitions (hospital admission, transfers between wards, discharge) 2
• Consider using an individualized patient-held medication plan for self-management support 1
• Review the self-management plan to ensure the person does not have problems using it 1

Organizational Considerations

• Implement a multidisciplinary team approach, especially involving clinical pharmacists when available 2
• Consider using computerized decision support systems that support decision making and prescribing but do not replace clinical judgment 1
• Conduct regular self-assessment of the unit to improve quality of care and service 1
• Implement systems to capture and respond to patient feedback on their experience 1
• Keep thorough and accurate electronic patient records adapted to the specific care unit 1

Common Pitfalls and How to Avoid Them

• Avoid applying individual disease-oriented guidelines to patients with multimorbidity without consideration of interactions between diseases and treatments 1
• Be aware that newly introduced medications may not have reached steady state at discharge due to short hospital stays, requiring careful monitoring after discharge 1
• Recognize that cognitive dysfunction is frequently underdiagnosed in patients with multimorbidity and polypharmacy but has major impact on health status 1
• Avoid prescribing cascades where additional medications are prescribed to counteract side effects of other medications 1
• Remember that good guidelines are not cookbooks; they augment but do not replace clinical judgment 1