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Common Problems in Adult Medicine

Cardiology

  1. Keep K+ above 4 and Magnesium above 2 (don't replace for patients with ESRD or ARF unless you talk to someone first).
  2. Always compare ECGs to old.
  3. PO to IV furosemide is 2:1 (i.e. 40 mg of PO furosemide is 20 mg IV)
  4. PO hydralazine to IV hydralazine is 4:1.
  5. Toprol XL to metoprolol is 1.4 mg to 1 mg. Hold all beta-blockers for >12 hours in patients who are getting a stress test.
  6. Dry lungs are happy lungs. Diuresis will be used often.
  7. Beers Criteria lists many medications that should be avoided in "older adults."

Chest Pain

Relevant questions: Based on possible cause, ruling out scary stuff.

  1. Acute Coronary Syndrome (ACS): typically pressure type of pain, associated with shortness of breath, nausea, vomiting, diaphoresis, radiation. Assess for risk factors including history of prior MI, prior stenting procedures, DM, HTN, tobacco use, FHX, hyperlipidemia. MI can present atypically in women and diabetics.
  2. Aortic dissection: "tearing" pain that usually radiates to the back. Associated with HTN, smoking.
  3. Pneumothorax: Associated with COPD, trauma, central lines. Decreased breath sounds, hyperresonance. Deviation of the trachea away from the side of the PTX, hypoxia.
  4. PE: dyspnea, tachycardia, tachypnea, pleuritic chest pain, hypoxia, A-a gradient, possible hemoptysis.

Focused Exam

  1. Vital signs and pulse ox
  2. JVD, Hepatojugular reflux
  3. Cardiac exam
  4. Lung exam

Data

  1. EKG
  2. Electrolytes to assess bicarb, K, BUN, Cr and glucose
  3. CBC
  4. Troponin
  5. CTPE if concern for PE
Type Troponins ECG changes
STEMI Positive ST elevations or new LBBB
NSTEMI Positive May have ST depressions, T wave inversions, or ST elevations that don't meet criteria for STEMI
Unstable angina Negative +/- May have ST depressions, T wave inversions, or ST elevations that don't meet criteria for STEMI

Treatment

  1. Telemetry
  2. Exact treatment depends on etiology - obtain EKG and discuss with senior
  3. Probable Cardiology consult.

Daily F/U

  1. Vitals and 02 sat
  2. Adequacy of symptoms control

Atrial Fibrillation

Relevant questions

  1. Symptoms: palpitations, syncope, chest pain
  2. Medication adherence issues ?
  3. Ever been told about atrial fibrillation before?
  4. On anticoagulation? Which medication? Compliant?

Focused Exam

  1. Cardiac exam
  2. JVD, carotid bruits
  3. Brief neurologic exam

Data

  1. EKG
  2. Electrolytes to assess bicarb, K, BUN, Cr and glucose
  3. TSH reflex
  4. CBC
  5. Troponin

Treatment

  1. If hemodynamically unstable: cardioversion (synchronized, start 200 J)

  2. If stable, control rate

    • Tip: be careful when using β-blockers and Calcium channel blockers together, as the combination may cause excessive AV nodal blockade.

    • β-blockers: don't give if actively wheezing or if in decompensated heart failure.

      i. Metoprolol PO if rate is relatively slow and patient is stable

      ii. Metoprolol 5 mg IV X 3

      iii. Esmolol gtt- good to consider in ICU patients

    • Calcium channel blockers: Contraindicated with VT, 2nd /3rd degree heart block without pacer, severe hypotension, cardiogenic shock, bypass tracts, EF < 40%

      i. Diltiazem: bolus administration (0.25 mg/kg up to 20 mg) and if that does not work, then gtt

    • Digoxin: caution in renal failure. Less hypotension. Controls rate at rest, but not with exercise. Slower onset. Remember to check levels.

    • Amiodarone: long term side effects. Consider in unstable patients or patients with CHF who need rate and rhythm control, do not order without senior as patients who are not anticoagulated can revert to sinus rhythm and throw a clot

  3. Anticoagulation

  4. Do they need it? Calculate Chads2Vasc
  5. Discuss with team based on comorbidities and likelihood of adherence - DOAC vs Warfarin (UpToDate guidance here)

Daily F/U

  1. Telemetry monitor
  2. Vitals - HR and BPs especially
  3. Ability to hold conversation, move around in room and attend to personal needs
  4. Adequacy of rate control - goal <110 bpm
  5. Patient/family understanding of progress and plan, and expectation for discharge

CHF Exacerbation

Relevant questions

  1. Symptoms

    • Quantify exercise tolerance and compare to baseline
    • Length of symptoms
    • Change in shortness of breath
    • Change in leg swelling or weight

  2. Any dietary changes?

  3. Has there been a need to use more diuretics?
  4. Inability to get or take medications
  5. Dry weight? (weight when adequately diuresed)
  6. Setting-from home or nursing home

Focused Exam

  1. Vital signs and pulse ox
  2. Able to speak in complete sentences?
  3. Respiratory rate and work of breathing
  4. Leg edema
  5. JVD and HJR
  6. Cardiac - murmur, gallop?
  7. Lungs-Breath sounds, crackles to where?

Data

  1. CXR on admission and with clinical change
  2. EKG
  3. Electrolytes to assess bicarb, K, BUN, Cr and glucose
  4. BNP
  5. Consider troponin if pain
  6. CBC

Treatment

  1. 02 to oxygen saturation > 88%
  2. Volume guided diuresis: diuresis to dry body weight or renal stress
    • Can use: Lasix, bumex, torsemide.
    • Lasix usually first line unless patient does not respond.
    • If patient is not Lasix-naive, will need to double their home dose and see how much they put out
  3. Daily weights and strict I/Os
  4. DVT prophylaxis (heparin for Cr clearance < 30)

Daily F/U

  1. Vitals and 02 sat
  2. Ability to hold conversation, move around in room and attend to personal needs
  3. Weight, net negative volume
  4. Edema, lung exam, JVD
  5. Patient understanding of progress and plan, and expectation for discharge
  6. Follow up with family if needed

Pulmonology

Pneumonia

Relevant questions

  1. Symptoms

    • Quantify exercise tolerance and compare to baseline
    • Length of symptoms
    • Cough? With sputum?

  2. Any exposures?

    • Sick contacts
    • Environmental
    • Tobacco use, prior or current

  3. Prior pneumonias?

  4. Setting: from home or nursing home, recent hospitalizations

Focused Exam

  1. Vital signs and pulse ox
  2. Able to speak in complete sentences?
  3. Respiratory rate and work of breathing
  4. Accessory muscle use
  5. Lungs-Breath sounds, Air Exchange

Data

  1. CXR on admission and with clinical change
  2. EKG
  3. Electrolytes to assess bicarb, K, BUN, Cr and glucose
  4. CBC
  5. ABG/VBG if concern for acidosis or failure to compensate (helpful to know baseline pCO2)
  6. RPP

Treatment

  1. 02 to oxygen saturation > 88%
  2. Antibiotics - options include respiratory fluoroquinolone (but not if prolonged QTc), macrolide, ceftriaxone.
  3. Respiratory care protocol - incentive spirometer.
  4. DVT prophylaxis (heparin for Cr clearance < 30)

Daily F/U

  1. Vitals and 02 sat
  2. Ability to hold conversation, move around in room and attend to personal needs
  3. Adequacy of symptoms control
  4. Day of hospitalization and course of antibiotics
  5. Need for further reimaging
  6. Patient understanding of progress and plan, and expectation for discharge
  7. Follow up with family if needed

COPD Exacerbation

Relevant questions

  1. Symptoms

    • Quantify exercise tolerance and compare to baseline
    • Length of symptoms
    • Change in sputum
    • Change in cough
    • Increase in oxygen requirement (how many liters do they use at home)

  2. Any exposures?

    • Sick contacts
    • Environmental

  3. Has there been a need to use more medication?

  4. Inability to get or take medications
  5. Setting-from home or nursing home

Focused Exam

  1. Vital signs and pulse ox
  2. Able to speak in complete sentences?
  3. Respiratory rate and work of breathing
  4. Accessory muscle use
  5. Paradoxical breathing
  6. Lungs-Breath sounds, Air Exchange

Data

  1. CXR on admission and with clinical change
  2. EKG
  3. Electrolytes to assess bicarb, K, BUN, Cr and glucose
  4. CBC
  5. ABG/VBG if concern for acidosis or failure to compensate (helpful to know baseline pCO2)
  6. RPP

Treatment

  1. 02 to oxygen saturation > 88%
  2. Bronchodilators via MDI with spacer during COVID-19 outbreak (albuterol and ipratropium)

  3. Steroids

    • 40mg daily for 5 days. IV Solu-Medrol initially in severe presentation.

  4. Antibiotics-azithromycin 500 mg for 3 days

  5. DVT prophylaxis (heparin for Cr clearance < 30)

Daily F/U

  1. Vitals and 02 sat
  2. Ability to hold conversation, move around in room and attend to personal needs
  3. Adequacy of symptoms control
  4. Day of hospitalization and course of antibiotics
  5. Need for further reimaging
  6. Patient understanding of progress and plan, and expectation for discharge
  7. Follow up with family if needed

Gastroenterology

GI Bleed

Relevant questions

  1. Symptoms

    • When did it start
    • Number of episodes
    • Associated lightheadedness, palpitations, syncope, pain?
    • What does the emesis (or BM) look like? Bright red blood or dark blood?
      • For BM - black, tarry = melena
    • Medication use - especially NSAIDs, anticoagulants
    • Alcohol use? How much (get specific)?
    • Prior bleeding history?
    • Liver disease? Known GI disease?

Focused Exam

  1. Vital signs
  2. Orthostatic blood pressure: + indicates ~20% volume loss
  3. Abd exam - tenderness? Hepatomegaly?
  4. Skin exam - jaundice, spider angiomata, bruising
  5. Consider rectal exam

Data

  1. Type & screen
  2. Electrolytes to assess bicarb, K, BUN, Cr and glucose (BUN >> Cr suggests upper GI bleed)
  3. CBC - discuss interval of repeat with team
  4. Coags - PT/INR, PTT
  5. EKG

Treatment

  1. 2 large bore IVs
  2. NPO and GI consult
  3. Transfuse for Hgb <7
  4. IV PPI - Pantoprazole 40 mg IV BID
  5. HOLD DVT prophylaxis

Daily F/U

  1. Vitals
  2. Further episodes of bleeding
  3. CBC stability
  4. GI recommendations, need for further testing
  5. Patient understanding of progress and plan, and expectation for discharge
  6. Follow up with family if needed

Transaminitis, Hepatic Encephalopathy

Relevant questions

  1. Symptoms

    • Abdominal pain
    • Last known normal if encephalopathic
    • Alcohol consumption? How much, when last (to figure out risk of withdrawal seizure)

  2. Any medications? Using too much tylenol?

  3. Who is their GI specialist?

Focused Exam

  1. Vital signs
  2. Orientation/mental status
  3. Neuro: Look specifically for asterixis, ataxia, slurred speech
  4. Abdominal exam - hepatomegaly, abdominal pain, ascites (is there enough to tap - figure that out BEFORE antibiotics)
  5. Skin exam - jaundice, spider nevi

Data

  1. Electrolytes to assess bicarb, K, BUN, Cr and glucose
  2. LFTs
  3. PT/INR
  4. Consider: acute hepatitis panel, iron studies, serology for CMV and EBV
  5. RUQ US

Treatment

  1. Lactulose for hepatic encephalopathy - titrate to 3-4 bowel movements per day
  2. Consider addition of Rifaximin based on team discussion
  3. Nutritional support - consider calorie count, high protein diet
  4. Discuss DVT prophylaxis (heparin for Cr clearance < 30) with team before ordering

Daily F/U

  1. Vitals
  2. Trend of LFTs, INR
  3. Calculate MELD score
  4. Assess ability to hold conversation, mental status
  5. Bowel movements if hepatic encephalopathy
  6. Patient understanding of progress and plan, and expectation for discharge - dispo plan
  7. Follow up with family if needed

Renal

Acute Renal Failure (ARF), Acute Kidney Injury (AKI)

Relevant questions

  1. Symptoms
    • Change in urine output or appearance
    • Change in weight or PO intake
  2. Change in medications? New or same medications with dose changes
  3. Any change in mental status?
  4. Known creatinine baseline and dry weight
  5. If dialysis patient - who is their nephrologist? Adherent with HD? Last session?

Focused Exam

  1. Vital signs
  2. Volume status - JVD, HJR, edema
  3. Mental status - are they uremic? (confused, itchy, sleepy)
  4. If HD patient - fistula site look okay? Palpable thrill?

Data

  1. Electrolytes to assess bicarb, Na, K, BUN, Cr

    • AKI is defined as increase in Cr ~30% from baseline

  2. EKG - especially if hyperK

  3. CBC
  4. Consider: urine lytes since you can use to calculate FeNa here (if not on loop diuretics)
  5. Intake/output

Treatment

  1. HOLD nephrotoxic medications - includes ACEi, NSAIDs
  2. Hydration - discuss with team based on assessed volume status
  3. Generally ok to continue DVT prophylaxis (heparin for Cr clearance < 30)

Daily F/U

  1. Vitals
  2. Daily creatinine - trend for improvement/back to baseline
  3. Urine output
  4. Patient understanding of progress and plan, and expectation for discharge
  5. Follow up with family and with PCP for recheck if needed

Acid/Base

Initial Approach

  1. Look at the pH. Whichever side of 7.4 the pH is on, the process that caused it to shift to that side is the primary disorder (i.e. acidosis or alkalosis). This is because the body never fully compensates for the primary acid-base disorder
  2. Calculate the anion gap. Look at the compensation. For a metabolic process the pCO2 should increase (metabolic alkalosis) or decrease (metabolic acidosis). For a respiratory process, the bicarbonate should increase (respiratory acidosis) or decrease (respiratory alkalosis)
3-common-problems-in-adult-medicine-1 diagram

Focused Exam

  1. Vital signs
  2. Respiratory status - respiratory rate? Retaining CO2?
  3. Urine appearance if available, output

Data

  1. BMP
  2. VBG
Disorder pH pCO₂ HCO₃⁻ Clinical examples
Respiratory and metabolic acidosis Very low ↑ Lower than expected Cardiopulmonary arrest, cerebrovascular accident and renal failure
Respiratory and metabolic alkalosis Very high ↓ Higher than expected Congestive cardiac failure and vomiting, diuretic therapy and liver failure
Metabolic acidosis and respiratory alkalosis ≈7.45 Lower than expected ↓ Salicylate overdose, septic shock, sepsis and renal failure
Metabolic alkalosis and respiratory acidosis ≈7.45 Higher than expected ↑ Diuretic therapy or vomiting and emphysema
Metabolic acidosis and metabolic alkalosis ≈7.45 → → Lactic acidosis or diabetic ketoacidosis and vomiting
Triple disorder: mixed metabolic acidosis and alkalosis plus respiratory alkalosis or acidosis Variable Variable Variable Renal failure, vomiting and congestive cardiac failure

Treatment

  1. Focused on underlying cause - discuss plan with team

Daily F/U

  1. Vitals
  2. Respiratory status - off of NIPPV? Or set up with home CPAP?
  3. Renal function - back at baseline?
  4. Clarify follow-up plan with patient and family

Hypertension

Relevant questions

  1. Symptoms: Headache, chest pain, palpitations, lightheadedness/syncope, abdominal pain
  2. Any medications for blood pressure? Have they changed at all?
  3. Changes to diet or activity level? Increased weight? Family history of hypertension?
  4. Do they know normal blood pressures for them

Focused Exam

  1. Vital signs
  2. Cardiac - murmurs, carotid bruit
  3. Abdominal - bruits, palpable mass
  4. Extremities - edema, pulses
  5. Fundoscopic exam if possible

Data

  1. EKG
  2. Electrolytes to assess bicarb, K, BUN, Cr
  3. CBC
  4. TSH reflex, cholesterol fractionation
  5. Urinalysis

Treatment

  1. Step 1: Rule out hypertensive emergency (ie SBP>180 or DBP>120 AND end-organ damage

    • (AMS/encephalopathy, visual changes, SOB, angina/ACS, renal damage, aortic dissection, CVA/ICH, acute CHF).
    • If symptomatic, should get EKG, trop, BMP, and UA for proteinuria. Typically need to initiate BP drip (nitro, nicardipine, etc.) and go to Cardiac ICU.

  2. Step 2: Treat anxiety, pain, look at home meds and/or meds received for the day.

  3. Step 3: Per 2017 ACC/AHA guidelines, do not treat hypertensive urgency (aka asymptomatic elevated BP without end organ damage) with IV meds.

    • Ideally: increase or restart chronic BP meds (but may get pushback)
    • If necessary, can give PRN labetalol (5-10 mg IV)
    • Alternative agent is hydralazine (5-10 mg IV) but generally not recommended due to unpredictable and prolonged antihypertensive effects

  4. Typically, you want gradual MAP reduction by 20-30% over 24 hours if hypertensive urgency or over 2-4 hours in HTN emergency

  5. Good oral antihypertensives

    • Initial therapy ideally with ACEi/ARB or dihydropyridine CCB (ie Amlodipine), consider thiazide diuretic, chlorthalidone (ALLHAT)
    • Base therapy decision on comorbid conditions and degree of hypertension on discussion with team if starting antihypertensives (or adding new ones)
    • JNC8 recommends maximizing first antihypertensive before adding another agent

  6. DVT prophylaxis (heparin for Cr clearance < 30)

Daily F/U

  1. Vitals and 02 sat
  2. Adequacy of BP control with oral medications
  3. Ability to obtain/take medications outpatient
  4. Patient understanding of progress and plan, and expectation for discharge

Infectious Disease

Sepsis

Relevant questions

  1. Symptoms

    • Any focal symptoms

      i. Urine changes? Color, frequency, pain, volume

      ii. Cough, shortness of breath, sputum

      iii. Congestion, sore throat, ear pain, sinus pain

      iv. Abdominal pain, diarrhea, nausea/vomiting

      v. Rash, swelling, pain

    • Syncope, lightheadedness

  2. Any exposures?

    • Sick contacts
  3. Prior history?
    • Previous infections with emphasis on resistant organisms in the past
  4. IV drug use or other substance use
  5. Setting: from home or nursing home. Recent hospitalization

Focused Exam

  1. Vital signs and pulse ox
  2. Able to speak in complete sentences?
  3. Skin - rashes, edema
  4. Cardiac - new murmur
  5. Abdominal - pain, distension
  6. Back – palpate spine
  7. Lungs-Breath sounds, Air Exchange, focal findings

Data

  1. CXR on admission and with clinical change
  2. EKG
  3. Electrolytes to assess bicarb, K, BUN, Cr and glucose
  4. CBC
  5. Blood cultures
  6. Urinalysis (urine culture must be ordered separately)
  7. RPP
  8. Lactate
  9. Consider echocardiogram if suspicion for endocarditis - d/w team
  10. Consider c-diff or stool studies depending on symptoms, antibiotic exposure

Treatment

  1. Vancomycin 15mg/kg q12h - adjust based on renal function
  2. Zosyn 3.375 or 4.5 mg q6h - also adjust based on renal function
  3. Narrow antibiotics after pathogen determined
  4. Fluid resuscitation with LR preferentially - goal MAP > 60 at least, so if not there/improving after 3-4 liters would consider escalating care
  5. DVT prophylaxis (heparin for Cr clearance < 30)

Daily F/U

  1. Vitals and 02 sat
  2. Testing results - do you have a source?
  3. Day of hospitalization and course of antibiotics
  4. Need for further reimaging
  5. Patient understanding of progress and plan, and expectation for discharge
  6. Follow up with family if needed

Acute Cystitis

Relevant questions

  1. Symptoms

    • Pain with urination
    • Increased frequency of urination
    • Nausea/vomiting, inability to tolerate PO intake

  2. Any prior history?

    • What has worked in the past? On chronic suppression?
    • Foley catheter?

  3. Setting-from home or nursing home

Focused Exam

  1. Vital signs
  2. Abdominal exam - suprapubic tenderness, CVA tenderness

Data

  1. Urinalysis, urine culture
  2. Electrolytes to assess bicarb, K, BUN, Cr and glucose
  3. CBC

Treatment

  1. Do NOT treat if asymptomatic! Review exceptions.

  2. Antibiotics - consider looking at our antibiogram and patient's prior UTIs if any

    • PO options: Nitrofurantoin (definitely do not use if eGFR <30, cautious with 30-60), Levofloxacin, Ciprofloxacin, Cephalexin
    • IV: Ceftriaxone, Zosyn, Levofloxacin, Meropenem if prior hx of ESBL

  3. DVT prophylaxis (heparin for Cr clearance < 30)

Daily F/U

  1. Vitals
  2. Day of hospitalization and course of antibiotics
  3. Need for further reimaging or outpatient follow-up
  4. Patient understanding of progress and plan, and expectation for discharge
  5. Follow up with family if needed

Neurology

Encephalopathy

Relevant questions

  1. Symptoms

    • Quantify length of time over which symptoms developed
    • Fevers, rashes, other infectious symptoms?
    • Change in PO intake, urine output
    • Abnormal movements or episodes of LOC?

  2. Ask family/NH staff for collateral information

    • Concerns? Change over time? Ability to care for self at home? Sick contacts?
    • Baseline function
    • Medication changes?
    • Setting - from home or nursing home

Focused Exam

  1. Vital signs
  2. Neurologic exam
  3. Mental status assessment

Data

  1. BMP, LFTs, ammonia
  2. CBC
  3. VBG

  4. Infectious testing: urinalysis (+ culture if suggestive of UTI), blood culture, CXR

    • Consider LP, particularly if febrile

  5. Urine tox screen

  6. Thyroid, serum osm tests. Consider B12, cortisol
  7. CT Brain non-contrast to start
  8. Further work-up to consider (often with Neuro input): MRI brain, EEG

Treatment

  1. Depends on etiology
  2. Consider seroquel, haldol only prn for severe agitation
  3. Thiamine for patients with hx of alcohol abuse, severe malnutrition
  4. DVT prophylaxis (heparin for Cr clearance < 30)

Daily F/U

  1. Vitals
  2. Improvement in mental status?
  3. Need for further workup/consultants on board?
  4. Patient/family understanding of progress and plan, and expectation for discharge

Endocrinology

Diabetes Mellitus

Relevant questions

  1. Symptoms

    • Do they know what their glucose has been recently? Highs or lows?
    • Do they have symptoms with highs and lows?
    • Any abdominal pain, nausea/vomiting, lightheadedness, clamminess?
    • Change in diet?
    • Home glucose - device monitoring levels/log?

  2. Has there been a recent change to insulin?

  3. Have they been in the hospital for problems with diabetes? Recently?
  4. Inability to get or take medications
  5. Setting - from home or nursing home

Focused Exam

  1. Vital signs
  2. Fingerstick glucose
  3. Basic neuro assessment - are they mentating appropriately
  4. Abdominal exam

Data

  1. Fingerstick glucose TID AC and QHS
  2. Electrolytes to assess bicarb, K, BUN, Cr and glucose
  3. Hemoglobin A1c if no recent one available

Treatment

Endotool protocol is used in the hospital. Remember to follow-up with glucose changes.

  1. Insulin - adjust daily based on previous 24 hours insulin requirements

    • Total Daily Dose (TDD) = sum total of all insulin scheduled to be given during a 24 hr period
    • Initial TDD for type 2 diabetes: 0.3 – 0.4 units/kg/day. For type 1, use 0.3 – 0.8 units/kg/day

    • 50% of TDD is given as basal insulin, 50% as rapid- acting insulin distributed across 3 meals

      • Basal Insulin = long acting insulin required to maintain normal BG overnight and while NPO
      • Mealtime Bolus Insulin = rapid-acting insulin used to cover meal-induced rise in glucose

    • Continue basal insulin (glargine/Lantus, NPH) at outpatient doses or cut in 1⁄2 if NPO

  2. Goals: avoid hypoglycemia, severe hyperglycemia, and electrolyte abnormalities

    • Critically ill patients: < 140 mg/dl, tight control 80- 110 mg/dl may be associated with increased mortality
    • Non–critically ill patients: premeal BG levels between 90–130 mg/dl, all fasting BG < 180 mg/dl

  3. Oral medications: hold metformin and sulfonylureas upon admission in most cases

Daily F/U

  1. Vitals
  2. Adequacy of glucose control
  3. Plan for outpatient follow-up
  4. Patient/family understanding of plan

Disclaimer

Always verify with your superiors before taking action based on this guide. The information is intended to help, but not to dictate your course of work. Always use critical judgment and your clinical knowledge skills. This guide will be constantly revised and updated according to evidence-based medicine.

Last update: April 12, 2026