What is the approach to management, investigation, and diagnosis of internal medicine cases?

Systematic Approach to Internal Medicine Case Management

Initial Clinical Assessment Framework

Begin with focused identification of high-risk features and disease severity stratification, as this determines the urgency and intensity of subsequent management. 1

Risk Stratification Priority

• Identify patients at risk for adverse outcomes by assessing for major risk factors: fever >38°C, subacute symptom progression over days/weeks, evidence of organ dysfunction (SOFA score increase ≥2 points), hemodynamic instability (SBP <90 mmHg for >30 minutes or requiring vasopressors), or signs of end-organ hypoperfusion (lactate >2 mmol/L). 1

• Assess for septic shock defined as vasopressor requirement to maintain MAP ≥65 mmHg plus serum lactate >2 mmol/L in absence of hypovolemia, which carries mortality rates of 67.8% versus 1.2% in non-septic patients. 1

• Document specific social and functional risk factors including inability to manage day-to-day activities, not living independently, limited health literacy, advanced age, multiple uncoordinated healthcare providers, and high treatment burden from polypharmacy. 1

Diagnostic Investigation Algorithm

Step 1: Targeted History and Physical Examination

• Document all known diagnoses, current medications (including over-the-counter and herbal supplements), and medication-related problems in the electronic medical record, using structured questionnaires when available. 1

• Assess specific clinical domains systematically: chronic pain management, depression/anxiety, incontinence, nutritional/hydration status, physiological and functional status, and presence of cognitive impairment. 1

• Evaluate psychosocial context including mental health, general wellbeing, quality of life impact, caring responsibilities, and barriers to self-management (language problems, health literacy limitations). 1

Step 2: Laboratory Testing

• Obtain baseline inflammatory markers (CRP and/or ESR), markers of myocardial injury (CK, troponins), complete blood count with differential (neutrophilia suggests inflammatory processes), comprehensive metabolic panel, and lactate level. 1, 2

• Perform blood cultures within the first hour of hospital arrival if infection is suspected, before initiating antimicrobial therapy when possible. 3

Step 3: Imaging Studies (Step-Up Approach)

• Use CT with intravenous contrast as the primary imaging modality for most acute internal medicine presentations requiring imaging, particularly for suspected intra-abdominal pathology or when clinical examination is inconclusive. 1, 2

• Reserve ultrasound as initial imaging for pregnant patients, pediatric patients, or when radiation exposure is a concern, progressing to CT only if ultrasound is inconclusive. 1

• Consider MRI for pregnant patients with abdominal complaints when ultrasound is non-diagnostic, though low-dose CT can be used in selected cases. 1, 2

Management Decision Framework

For Hemodynamically Unstable Patients

• Proceed directly to definitive intervention (surgical consultation, invasive hemodynamic monitoring, or ICU admission) without delay for extensive imaging if clinical diagnosis is clear and patient shows signs of shock or organ failure. 1, 2

• Initiate empiric antimicrobial therapy immediately for suspected infection while diagnostic workup proceeds, using broad-spectrum agents effective against likely pathogens based on clinical syndrome. 1, 3

For Hemodynamically Stable Patients

• Complete diagnostic imaging and laboratory evaluation before definitive intervention, using results to guide targeted therapy. 1, 2

• Perform comprehensive medication review evaluating risk-benefit of each drug, possible interactions and adverse effects, adherence patterns, and unmet therapeutic needs, with particular attention to prescribing cascades. 1

• Conduct medication review at least annually, more frequently during hospital stays (on admission, ward transfers, and discharge), using multiple methods including health record reviews, patient surveys, home visits, and direct observation. 1

Multidisciplinary Interaction Assessment

• Assess all disease-treatment interactions including potential drug-drug interactions, drug-disease interactions, adverse drug reactions, medication underuse, and treatment burden on the patient. 1

• Involve patients and family members/carers in the assessment process, actively clarifying and resolving misconceptions about their conditions and treatments. 1

• Coordinate with other healthcare professionals by exploring the patient's contacts with specialists and any related management changes, considering information technology support and multidisciplinary team-based approaches. 1

Patient-Centered Treatment Planning

• Elicit patient's personal values, aims, and priorities before making treatment recommendations, addressing medical, psychological, emotional, social, spiritual, and cultural needs. 1

• Follow a three-step preference elicitation process: (1) recognize when facing a preference-sensitive decision, (2) ensure adequate information about expected benefits and harms, (3) elicit preferences only after sufficient patient understanding. 1

• Establish disease and treatment burden including effects on day-to-day life, mental health, general wellbeing, quality of life, and additional burden from caring responsibilities. 1

• Discuss the purpose of the care approach explicitly (e.g., improving quality of life and function, reducing treatment burden, optimizing care by identifying medication improvements or reducing inappropriate medications). 1

Monitoring and Follow-Up Strategy

For Suspected Treatment Failure

• Investigate persistent or recurrent clinical evidence of ongoing disease after 4-7 days of therapy with appropriate diagnostic studies (CT or ultrasound imaging), continuing antimicrobial therapy effective against initially identified organisms. 1

• Consider extra-abdominal sources of infection and non-infectious inflammatory conditions if inadequate response to microbiologically appropriate initial therapy. 1

• Obtain both aerobic and anaerobic cultures from at least 1.0 mL of fluid or tissue transported in anaerobic system, or inoculate 1-10 mL directly into anaerobic blood culture bottle. 1

Serial Examination Protocol

• Perform serial examinations to increase diagnostic accuracy, particularly in patients managed non-operatively or when initial diagnosis is uncertain. 2

• Ensure follow-up within 24 hours for patients discharged without definitive diagnosis, even if by telephone, as false-negative imaging rates are measurable and other conditions may manifest during this interval. 1

Critical Pitfalls to Avoid

• Never delay intervention based solely on negative imaging when clinical suspicion remains high; diagnostic laparoscopy has higher sensitivity and specificity than radiological assessment and should not be delayed. 2

• Avoid attributing all symptoms to a single diagnosis in patients with multimorbidity; systematically assess for concurrent conditions and medication-related problems. 1

• Do not assume level of desired involvement in decision-making; explicitly ask patients what level of participation they prefer rather than making assumptions. 1

• Recognize that physical examination findings may be masked by distracting injuries, head injuries, spinal cord injuries, or medications, necessitating lower threshold for imaging. 2