5 Patients Notes October 10th 20.....

Progress Note

Date: 10/9/25
O₂: Room air
Mobility: Ambulatory
Communication: Tangential, disorganized; limited cooperation with exam

HPI

66-year-old male with past medical history of type 2 diabetes mellitus (DM), coronary artery disease (CAD), hypertension (HTN), hyperlipidemia (HLD), peripheral vascular disease (PVD), and tobacco use, brought to the ED by EMS for bizarre behavior, paranoia, and reported suicidal ideation (“plan to cut throat”).

Patient lives alone in a multistory home; unclear if he currently receives VNA support. Brother, who is the patient’s POA, reports 6–7 months of progressive cognitive and behavioral changes beginning around June, including intermittent confusion, nonsensical text messages, and poor oral intake. Symptoms would fluctuate but never return to baseline. Over the last two weeks, confusion has worsened with paranoia, disorganized behavior, and delusional beliefs (believing messages were hacked, or that people were following him).

EMS found the patient disheveled, incontinent of urine, and confused. On ED arrival, he was disorganized and tangential, unable to provide coherent history. Denies chest pain, dyspnea, headaches, or drug use. Admits to a cough.
Brother notes a remote history of alcohol abuse, reduced 3–4 years ago. No known psychiatric history apart from past depression. No recent travel, hiking, or camping.

Recent ED Visits:

• 7/28: HTN crisis (BP 199/70); admitted noncompliance with medications

• 9/29: Altered mental status (AMS), incoherent speech; friend noted nonsensical texts and confusion for weeks

Current presentation: pacing, refusing to sit or participate in exam; denies pain or dyspnea.

Physical Exam

• General: Disheveled, pacing, cooperative but tangential

• Neuro: Difficult to assess due to poor cooperation; no focal deficit appreciated

• Cardiac/Respiratory: No acute distress; room air

• Abdomen: Soft, nondistended

• Skin: Intact

• Psych: Disorganized thought process, paranoia, no clear hallucinations; denies current suicidal or homicidal ideation

Assessment & Plan

Acute Psychosis vs. Delirium

New-onset paranoia, confusion, and bizarre behavior over months, worsened in recent weeks. Differential includes:

• Delirium (infectious/metabolic, medication effect)

• Primary psychiatric disorder (late-onset psychosis, major depression with psychosis)

• Dementia with behavioral disturbance

• Substance-related etiology (remote alcohol history)

Plan:

• Delirium workup: CBC, CMP, TSH, B12, folate, RPR, ammonia, urine tox, UA

• Brain MRI or CT to rule out structural process

• Review recent medication adjustments (per cardiologist)

• Psychiatry consult for behavioral and safety evaluation

• Implement sitter and suicide precautions

• Monitor for alcohol withdrawal symptoms

Hypertension / CAD / HLD / PVD

Chronic conditions; recent noncompliance with antihypertensive regimen.

Plan:

• Continue lisinopril 20 mg daily

• Continue metoprolol tartrate 12.5 mg BID

• Continue rosuvastatin 40 mg nightly

• Continue aspirin 81 mg daily

• Encourage adherence and monitor BP

Cough / Possible Infectious Etiology

Given concurrent antibiotic therapy and mild leukocytosis, possible community-acquired pneumonia or bronchitis considered.
Plan:

• Continue ceftriaxone 1 g IV q24h

• Continue doxycycline 100 mg PO q12h

• Monitor WBC, temperature, oxygen saturation

Diabetes Mellitus

Monitor for poor intake or fluctuating blood glucose related to altered mental status.
Plan:

• Check fasting and bedtime glucose

• Reassess home regimen once mental status stabilizes

Alcohol Use Disorder (Remote)

History of heavy use, reduced 3–4 years ago.
Plan:

• Monitor for withdrawal

• Thiamine supplementation if intake poor

• Social work consult for support/resources

Geriatric Assessment

Complexity: High

Home Environment: Lives alone, no confirmed home health support

Vision/Hearing: Wears glasses

Cognition: Previously intact per brother; now with months-long progressive behavioral changes

Mobility: Ambulatory; history of imbalance; no assistive device

ADLs: Independent in all
IADLs: Independent in all prior to current episode

Medications: Reconciliation incomplete — patient AMS; brother unsure of regimen

Decision Maker: Brother (POA)
Advance Directive: Present — Full Code per brother’s report

Current Medications

• Aspirin 81 mg PO daily

• Ceftriaxone 1 g IV q24h

• Doxycycline 100 mg PO q12h

• Enoxaparin 40 mg SQ daily

• Lisinopril 20 mg PO daily

• Metoprolol tartrate 12.5 mg PO BID

• Rosuvastatin 40 mg PO nightly

• Sodium chloride 0.9% flush 3 mL IV q8h

Disposition

• Continue inpatient medical evaluation for altered mental status

• Psychiatry and social work consultations

• Safety and fall precautions

• Consider eventual neurocognitive testing after acute stabilization

CODE STATUS: Full Code

Progress Note

Date: 9D
O₂: Room air
Communication: Nonverbal
Functional Status: Total care, bedbound
Incontinence: Bowel and bladder (x2), rectal tube in place
Musculoskeletal: Contracted

Subjective

85-year-old nonverbal female with advanced dementia, bedbound and fully dependent at baseline, lives at home with 24/7 aide. Past medical history includes dementia, HTN, HLD, CHF, seizures, recurrent UTIs, incontinence, and chronic sacral/coccygeal pressure ulcer. Presented with UTI and stool contamination of deep coccygeal wound.

Assessment & Plan

Deep Coccygeal Ulcer

Chronic, deep ulcer with recent contamination due to loose stools. Wound nurse typically visits 3x/week for dressing changes.

• Turn and reposition (T&R) every 2 hours

• Santyl (collagenase) adjusted 10/8 — continue nightly + BID PRN (7-day course)

• Follow up with wound nurse regarding decontamination frequency and Santyl application

• CT with IV contrast to assess for possible osteomyelitis

UTI / Leukocytosis

Recurrent UTIs, previously hospitalized 9/2025 for Klebsiella UTI. Current UA: WBCs, 3+ leukocytes, +nitrites, many bacteria. Completed 3-day course of ceftriaxone (10/6–10/8) with persistent leukocytosis. C. diff negative.

• Urine culture: >100K E. coli, <100K E. faecalis

• Start ampicillin for E. faecalis UTI (10/9–10/13)

• Continue monitoring intake/output

• Monitor for worsening diarrhea or C. diff recurrence given recent antibiotic use

Pain

• Morphine 5 mg PO or 2 mg IV every 4 hours PRN

Seizure Disorder

• Continue home Keppra 250 mg PO or 250 mg IV BID

Poor Oral Intake

Limited PO intake; calorie count over 3 days showed only 50% of one meal documented. Dietitian unable to fully assess; provided recommendations.

• Diet: Pureed, 1:1 feeds

• Encourage family (son) to visit and assist with feeding using familiar home purees

• Continue D5LR at 75 mL/hr + thiamine supplementation

• Replete electrolytes as needed

• Monitor potassium with daily BMP

• Dietitian recommendations:

  • Discontinue calorie count

  • Continue puree diet with 1:1 assistance

  • Add Ensure Plus TID and Magic Cup TID

  • Continue multivitamin, folic acid, and thiamine

  • Defer vitamin C and zinc sulfate x10 days due to poor PO tolerance and altered skin integrity

Disposition / Coordination

• Patient currently taking medications IV due to PO refusal

• Ongoing calorie and fluid monitoring

• Follow up with care coordination regarding expanded home support and wound care services

• Daily updates to son; discuss goals of care (GOC)

Summary of Orders

• Diet: Pureed, 1:1 feeding

• IV Fluids: D5LR 75 mL/hr

• VTE Prophylaxis: SCDs

• Wound Care: Santyl nightly + BID PRN

• Seizure Management: Keppra 250 mg PO/IV BID

• Pain Control: Morphine PRN

• Electrolyte Monitoring: Daily BMP

Disposition: Home with 24/7 aide and wound care; planning for live-in help
Code Status: DNR/DNI

Patient: Mary 88-year-old female

Past Medical History: Hyperlipidemia (HLD), Hypertension (HTN), Osteoporosis, History of TIA/CVA, Major Depressive Disorder (MDD) with prior ECT, Anxiety
Chief Complaint: Generalized weakness, ataxic gait, and fall

Assessment & Plan

Generalized Weakness / Mechanical Fall / Ataxic Gait

• Etiology: Likely multifactorial — post-vaccine, UTI, possible neurologic or neuromuscular cause.

• Findings:

  • Inability to stand on PT eval

  • Gait abnormality

  • No back pain

  • Neuro exam nonfocal

  • CT head/neck: no acute abnormalities

  • XR R lower leg: no acute osseous injury

  • XR ribs (L): no acute findings

  • B12: within normal limits

Plan:

• Obtain TSH, CK

• Lumbar X-ray

• MRI brain/spine

• Thiamine 100 mg IV daily

• Encourage PO intake

• PT recommends moderate complexity support on discharge

Urinary Tract Infection (UTI)

• Findings: Mild retention (improved), urinary urgency, UA positive for infection
  Plan:

• Follow up urine culture (UCx) 10/9

• Start ceftriaxone (10/9–10/11)

• PRN bladder scan and straight cath

Anxiety / Depression

• Findings: Tremulous/anxious in AM — likely withdrawal after missed lorazepam dose. Prior history of withdrawal with missed benzodiazepines.
  Plan:

• Continue escitalopram

• Clarify bupropion dosing with daughter

• Resume home lorazepam (0.5 mg AM, 1 mg PM)

Hypertension

• Likely due to: situational stress
  Plan:

• Continue to monitor (CTM)

• Continue home statin

Geriatric Assessment

Complexity: Multicomplex medical and psychosocial needs

Home Environment / Support:

• 24/7 aide

• Daughter (Maureen) lives nearby

Vision / Hearing:

• Vision impairment — requires large print

Functional Assessment:

Falls:

• Positive — 2 falls in past year

• Uses walker

ADLs:

• Bathing: Needs assistance

• Dressing: Independent

• Toileting: Independent

• Transferring: Independent

• Feeding: Independent

• Grooming: Needs assistance

IADLs:

• Telephone: Independent

• Shopping: Fully dependent

• Food preparation: Fully dependent

• Housekeeping: Fully dependent

• Laundry: Fully dependent

• Transportation: Fully dependent

• Medication management: Needs assistance (family portions out pills)

• Finances: Fully dependent

Cognition:

• Baseline: A&O ×3–4, intermittent confusion but redirectable

• Cognitive decline over past 6–12 months per daughter

• Chronic benzodiazepine use with past withdrawal episodes

• Concern for cognitive impairment: Yes

Medications

• Home medication reconciliation completed with family

• Medication system: family/aide prepares doses

• High-risk medication: lorazepam

Matters Most

• Surrogate decision-maker: Daughter (Maureen)

• Advance directive: None; consider Spiritual Care consult for completion during admission if appropriate

Additional Orders

• Diet: Cardiac

• Prophylaxis: SCDs

• Bowel regimen: Miralax/Senna PRN

• Disposition: Floor pending workup of weakness and completion of UTI treatment

Code Status: Full

Progress Note

Date: 10/9/25
O₂: 2 L/min NC (baseline)
Mental Status: Alert and oriented
Mobility: Ambulatory with walker
BP: Stable, off pressors

68-year-old female with oxygen-dependent COPD (80 pack-year smoker), history of NSCLC s/p right lower lobectomy and chemotherapy (2020), pacemaker, and chronic back pain from lumbar compression fractures (s/p IR kyphoplasty in August), admitted for shock requiring pressors, now hemodynamically stable and off pressors on baseline O₂.

Assessment & Plan

Shock / Fever of Unknown Origin

Likely septic shock of unclear source. Patient is clinically stable with normalized blood pressure and back to baseline O₂.
Labs: Elevated CRP and ESR, suggestive of inflammation/infection. No definitive infectious source identified.
Workup:

• Neuro: MRI (10/8) — no osteomyelitis.

• Ortho: Evaluated for possible L knee septic arthritis — unlikely per exam and imaging.

• Duplex U/S BLE — no DVT.
  Differential: Culture-negative endocarditis, septic arthritis, malignancy, autoimmune process, adrenal insufficiency.
  Plan:

• Continue Zosyn (10/2–10/10)

• Follow up NSG consult

  • No surgical intervention indicated

  • Continue TLSO brace from home when OOB

  • Outpatient follow-up with Neurosurgery in 2 weeks

• Consider outpatient malignancy screening after discharge

Suicidal Ideation / MDD (without psychosis)/ Prolonged Grief

Evaluated by Psychiatry for passive suicidal ideation (chronic, unchanged).
Psych recommendations:

• No need for inpatient psych admission or special observation

• Continue:

  • Fluoxetine 30 mg PO daily

  • Abilify

  • Mirtazapine

• Encourage ongoing discussion of Goals of Care (GOC) given recurrent statements about death/dying

• Support from rehab staff as patient ambulates with walker

Chest Pain (resolved)

Non-cardiac etiology likely.
Workup: EKGs and troponins normal; recent cath showed nonobstructive CAD.
Differential: Anxiety, musculoskeletal strain, GERD, or pleurisy.
Mild cough, no increased O₂ requirement; viral etiology possible.
Plan:

• Symptomatic management

• Continue current cardiac medications

• Monitor for recurrence

• Lactate normalized after 1 L LR

Chronic Back Pain/ Subacute L4 Compression Fracture

s/p Kyphoplasty; pain well controlled.
Plan:

• Tylenol PRN

• Continue pregabalin

• Hold flexeril (last filled 8/30)

• Continue diclofenac gel, lidocaine patch, calcitonin nasal spray

• TLSO brace from home

• Continue PT/OT per Spine/Neurosurgery recs

Left Knee Pain – Likely Osteoarthritis

Plan:

• Continue Tylenol, lidocaine patch, diclofenac gel

• RICE protocol

• Continue PT/OT

NSTEMI (prior) with Nonobstructive Coronaries / Hypertension

Stable, no acute cardiac ischemia.
Plan:

• Continue aspirin and statin

• Continue metoprolol tartrate 12.5 mg BID

• Hold amlodipine pending stability

COPD (on baseline 2L NC)

Stable respiratory status.
Plan:

• Continue Symbicort

• Duonebs and albuterol PRN

• Continue fludrocortisone (Florinef) 0.2 mg daily

Geriatric & Hospital Checklist

Mind:

• Delirium screen (CAM): Negative

• Last BM: 10/09/25

• No tethers/telemetry

• Cognitive screening: Normal

Mobility:

• As tolerated, ambulating with walker

Medications:

• Reviewed — no acute high-risk timing issues

Matters Most:

• Code Status: Full Code

• Emergency Contact: Brescia, Megan

Multicomplexity:

• Diet: Regular

• VTE Prophylaxis: Enoxaparin

• Disposition: Anticipate discharge to Cooney

Summary:
68F with complex pulmonary and musculoskeletal comorbidities, admitted for presumed septic shock now resolved, currently stable on baseline O₂. Pain, mood, and mobility well managed. Psychiatry and neurosurgery following. Continue antibiotics through 10/10, maintain supportive care, and coordinate discharge planning to Cooney with outpatient follow-up.

Progress Note

Date: 10/10/2025
Attending:
Service: Medicine
Code Status: NO CODE

Subjective

85-year-old male with history of dementia, multiple myeloma (C23D1 Dara + monthly IVIG 9/12/25; due 10/9/25), CLL (expectant management), Afib on Eliquis, HTN, HLD, BPH (on flomax and vibegron), and EtOH use.
Presents with malaise, fatigue, confusion, hypotension, and acute respiratory failure; found to have strep bacteremia concerning for sepsis likely secondary to pneumonia.

Wife reports baseline dependence for ADLs, ambulates with cane, no recent falls or elopement issues.

Objective

Vitals: Stable BP, afebrile, on baseline O₂ 2L NC.
Exam:

• Improved orientation compared to admission.

• Lungs with scattered rhonchi, no crackles.

• No LE edema, warm and perfused.

• Neuro: No focal deficits.

• Skin: No rashes or wounds noted.

Lines: R PIV, condom catheter
Diet: Regular

Assessment & Plan

Acute hypoxemic respiratory failure

Sepsis

Streptococcal bacteremia

Likely secondary to pneumonia, possibly aspiration-related given initial failed swallow eval. Urosepsis unlikely (negative culture, no urinary sx).

• Continue CTX + Vancomycin

• ID consult for speciation and workup (TEE or abd imaging if indicated)

• Monitor BCx for clearance

• CT PE negative, TTE normal, NT-proBNP elevated likely from Afib/renal dysfunction

• Continue O₂ 2L NC; monitor weaning

Atrial fibrillation

• Received IV metoprolol 5mg for HR 140s, now rate controlled

• Continue metoprolol tartrate 25mg q6h

• Continue Eliquis (dose reduced given age >80, Cr >1.5)

• Telemetry monitoring

Hyponatremia

Euvolemic on exam; likely secondary to infection.

• Check urine lytes, osmolality

• Monitor BMP daily

BLE edema / CKD / HTN

No signs of volume overload.

• Hold bumex and spironolactone

• Replete phos PRN

• Monitor Cr and electrolytes

Altered mental status

Moderate–severe dementia

AMS improving with infection management.

• Discontinue memantine (rash)

• Trazodone 25mg q8h PRN for agitation/sleep

• Melatonin nightly

• Continue discussions with wife re: GOC (remains NO CODE)

Multiple myeloma / CLL

Active treatment for MM; CLL under observation.

• Continue acyclovir prophylaxis

• Continue thiamine, folate, magnesium oxide, iron

• Hgb stable at baseline

BPH

• Foley discontinued; using condom catheter

• Holding flomax due to hypotension

• Home vibegron not on formulary — will consider resuming if family brings supply

Anxiety / Depression

• Decrease Lexapro from 20mg → 10mg (geriatric max effective dose)

• Continue bupropion

• Lorazepam 0.2mg BID PRN

 Hyperglycemia

Likely stress-related.

• Glucose peaked at 246, improved

• Follow-up A1c

Checklist

• Diet: Regular

• VTE prophylaxis: Eliquis

• Lines: R PIV, condom catheter

• Dispo: Pending medical improvement

• Code Status: NO CODE

Additional Case (separate admission)

88-year-old female with HLD, HTN, Osteoporosis, hx TIA/CVA, MDD (prior ECT), Anxiety, admitted for generalized weakness and mechanical fall, likely post-vaccination.

Findings:

• CT head/neck negative; X-rays with no acute findings.

• Encourage PO intake; PT evaluation ongoing.

• BP mildly elevated, monitor.

• Urinary retention: Intermittent bladder scan/straight cath PRN.

• Continue Lexapro, bupropion, and lorazepam 0.2 BID PRN.

• Diet: Cardiac

• DVT PPX: Compression stockings

• Code Status: Full Code