Real Cases Studies September 2025

 Patient 1

An 82 male Full Code

Situation:
Admitted 9/16 with chest pain. Diagnosed with acute chronic HFpEF exacerbation and hypertensive urgency. Now medically stable, pending PT eval.

Background:
PMHx: HTN, HLD, PAD (L TMA, R BKA), HFpEF, PAF, DVT/PE on Eliquis, ESRD on HD MWF, HIV on ART, SDH (L burr hole & MMA embolization 2024), recent R knee septic arthritis (on Vanco until 10/6). Notable comorbidities: thrombocytopenia, hypocalcemia, hyponatremia.

Assessment:

• BP improved but remains elevated (SBP up to 180s before meds).

• AOx3 on room air

• Reports pain and get PRN medications.
  
  

• Afib with bradycardia, Mobitz I, prolonged QTc.
  
  

• TTE EF 64%, troponins flat, PET MPI 8/27 normal.
  
  

• R knee septic arthritis improving on Vanco post-HD through the end of September.
  
  

• ESRD: nephrology following, HD MWF.
  
  

• Functional: AMPAC mobility score 11; max mobility = transfer to chair.

• Recommendation:

• Continue antihypertensives (Hydralazine, Norvasc, Imdur, Spironolactone, Coreg, Losartan, Doxazosin, PRN Clonidine). Monitor bradycardia/QTc.
  
  

• Continue HD regimen, diet, and phosphate binders.
  
  

• Continue Vancomycin post-HD; monitor labs weekly.
  
  

• PT/OT eval for discharge readiness.
  
  

• Anticipated discharge by mid-September to short-term rehab.
  
  

Patient 2

Situation:
A 88-year-old male, Full Code, presented with shortness of breath and chest pain. Found to have COVID-19, atrial fibrillation with RVR, and AKI (improved with IV fluids). Currently stable, awaiting cardioversion with EP on Tuesday.

Background:

• PMHx: HFpEF, CAD s/p PCI, atrial fibrillation on Eliquis, DM2, CKD, immune-mediated neuropathy on TPE, marginal zone lymphoma vs lymphoplasmacytic lymphoma of lung.
  
  

• Recent events:
  
  

• COVID-19 positive.
  
  

• Afib with RVR, managed with sotalol and metoprolol.
  
  

• AKI resolved with IV fluids.
  
  

• Unwitnessed fall, CT head/c-spine negative.
  
  

• Elevated but flat troponins, no ischemic changes on EKG.
  
  

• CTA chest negative for PE.
  
  

• BNP 11,674; EF 62% with mild LVH and TTE.
  
  

Assessment:

• COVID-19: On Remdesivir (day 3), sats stable on room air, cough managed with Robitussin DM.
  
  

• SOB/Chest pain: Troponins elevated but flat at this time. No ischemic changes. D-dimer positive but CTA chest negative.
  
  

• HFpEF: Volume overload on admission, improved after Lasix IV. Not compliant with home Lasix (supposed to take 20 mg PO BID but only takes on weekends). Continues on Jardiance.
  
  

• Afib with RVR: EP consulted. Cardiac CTA negative for LAA thrombus. Sotalol increased to 80 mg PO TID. Metoprolol 25 mg PO q6h continued. On Eliquis. NPO Monday night for cardioversion Tuesday.
  
  

• AKI: Improved; creatinine 1.50 → 1.10 → 1.30. Continue to monitor BMP.
  
  

• DM2: A1C 6.4. On Lispro sliding scale and Jardiance. Home Glipizide held.
  
  

• Unwitnessed fall: Likely mechanical. Imagining negative. PT evaluation pending.
  
  

• Labs: Thrombocytopenia and hyponatremia noted.
  
  

• Comorbidities on admission: Thrombocytopenia, hypercoagulable state (Afib), history of COVID.
  
  

Recommendation / Plan:

• Continue Remdesivir course for COVID.
  
  

• Continue Robitussin DM PRN for cough.
  
  

• Maintain HF regimen: Lasix, Jardiance, monitor volume status and BNP.
  
  

• Afib with RVR: Continue increased Sotalol and Metoprolol. Continue Eliquis. NPO plan for cardioversion Monday.
  
  

• Monitor renal function (daily BMP).
  
  

• Manage DM2 with Lispro SS and Jardiance; continue to hold Glipizide.
  
  

• Continue PT evaluation post-fall.
  
  

• Diet: Cardiac, consistent carbohydrate.
  
  

• VTE prophylaxis: Eliquis.

Patient 3 

40M, Full Code

Situation:
Admitted with septic shock from urosepsis and paraspinal abscess. Course complicated by respiratory failure, AKI, SBO. Now on floors, pending safe discharge disposition.

Background:
PMHx: Paraplegia from Gunshot wound s/p ileostomy, chronic Foley, recurrent UTI, chronic osteomyelitis, malnutrition s/p PEG. Chronic sacral wounds.

Assessment:

• Klebsiella bacteremia; osteomyelitis with epidural/psoas abscess s/p drain, cultures grew pseudomonas. CT stable. Drain removed. On Pip-Tazo through.
  
  

• Severe chronic back pain (palliative following). On multimodal pain regimen + opioids.
  
  

• Malnutrition, PEG feeds ongoing.
  
  

• Foley leakage chronic, upsized to 18Fr, currently stable.
  
  

• CKD3 with fluctuating Cr; dose meds for GFR 31.
  
  

• Recurrent hypercarbic resp failure, stable on nocturnal BiPAP.
  
  

• RLE DVT (on Eliquis).
  
  

• Stable sacral wounds and pleural effusions.
  

Recommendation:

• Continue Pip-Tazo IV through.
  
  

• Coordinate with Palliative Care for outpatient pain and antibiotic plan prior to discharge.
  
  

• Continue tube feeds, Foley care, nightly BiPAP.
  
  

• Adjust meds for renal dosing.
  
  

• Discharge pending safe outpatient support and pain/antibiotic coordination. 

Patient 4

65 y.o. male, Full Code
AOx4. OOB with one assist.

PMHx: AUD (no history of seizures or prior hospitalizations), multiple right-sided rib fractures, right rotator cuff tears, depression.

Presentation: Patient was found down by landlord, lying on the floor with a large right frontal bruise. On evaluation, he had a large bruise, small frontal laceration, and hematoma. CT Head negative for intracranial bleed. Started to have alcohol withdrawal symptoms, placed on diazepam. CK elevated, but rhabdo unlikely, elevations more likely from bruising.

Plan:

Presumed fall / Scalp hematoma

• Found down, patient does not remember details of event.
  
  

• CT Head negative for bleed.
  
  

• Likely mechanical fall, likely related to alcohol intoxication and deconditioning, with facial/head trauma.
  
  

• Orthostatic now normal after 500 mL bolus.
  
  

• PT: increased to moderate complexity.
  
  

• Consider outpatient heart monitor given fall.
  
  

Elevated CK

• CK low 2000s.
  
  

• UA negative for blood.
  
  

• No AKI, making rhabdo unlikely.
  
  

• Likely muscle injury from fall and prolonged time on floor.
  
  

Alcohol use disorder, c/b withdrawal

• Patient reports desire to quit alcohol.
  
  

• Addiction Medicine consulted.
  
  

• Start naltrexone PO inpatient and IM dose at discharge.
  
  

• Continue thiamine and folic acid.
  
  

• Discontinue CIWA and diazepam.
  
  

• Continue hydroxyzine PRN for anxiety.
  
  

Tobacco use

• Continue nicotine patch.
  
  

• Nicotine PRN as needed.
  
  

Macrocytic anemia

• Likely related to alcohol use and anemia of chronic disease.
  
  

• Iron and B12 levels normal.
  
  

• MMA pending.
  
  

Comorbidities

• Present on admission: as above.
  
  

• Secondary diagnoses during hospitalization: thrombocytopenia.
  

Orders:

Diet: Regular, with nutrition supplements.
VTE ppx: SCDs

Discharge Planning

• Readiness: Expected discharge
  
  

• AM-PAC (RN/PT):
  
  

• PT disposition recommendation: Moderate complexity
  
  

• Expected discharge location: Home with services.
  
  

• Barrier(s) to discharge: Overcoming alcohol withdrawal.