5N October

Progress Note

Date: 10/10/2025
Patient: Age/Sex: 57-year-old male
Code Status: Full Code

Chief Complaint: 

Suicidal ideation in the setting of alcohol intoxication

HPI

57-year-old male with PMHx of HTN, HLD, ADHD, depression, and anxiety with a history of suicidal ideation and a remote suicide attempt in 2010, recently admitted for SI and alcohol withdrawal, presents again for EtOH intoxication and supervised withdrawal management.

He reports drinking approximately 1.5 L of vodka daily, last drink prior to presentation. While intoxicated, he lost balance and fell forward, sustaining a nasal injury. He denies loss of consciousness, chest pain, palpitations, or recurrent falls, though notes feeling dizzy during intoxication.

He smokes 10–15 cigarettes/day and admits to occasional cocaine use (“a few times lately”). Endorses suicidal ideation without a specific plan or intent.

ED Course

• Vitals: BP 142/90, HR 81, Temp 34.9°C, SpO₂ 96% RA

• Labs:

  • Hgb 16.3, WBC 3.4, Plt 187

  • Cr 1.0, BUN 5

  • Na 147, Cl 108, CO₂ 28, AG 11

• Imaging:

  • CT head/facial bones/cervical spine: No acute intracranial abnormality; acute nasal bone fracture; no cervical spine fracture or traumatic subluxation (C7 incompletely visualized).

• ED Medications:

  • Cefazolin 2g IV x1

  • Valium 10mg PO x1

  • Droperidol 5mg IM x1

  • Thiamine 500mg IV x1

Assessment

Principal Problem:

• Facial laceration / nasal bone fracture (initial encounter)

Active Issues:

• Alcohol intoxication and withdrawal risk

• Suicidal ideation (without plan)

• Hypertension

• Depression and anxiety

• Tobacco and intermittent cocaine use

Plan

Alcohol intoxication / withdrawal risk

• Continue CIWA protocol, symptom-triggered Valium PRN

• Continue high-dose thiamine prophylaxis

• Initiate D5 ½ NS for hydration

• Monitor Na and electrolytes with AM labs

• Addiction Medicine consult in AM

Suicidal ideation / psychiatric evaluation

• Maintain suicide precautions, 1:1 sitter

• Psychiatry consult in AM for assessment and recommendations

• Social work consult for safety and outpatient resources

Facial laceration / nasal bone fracture

• S/p cefazolin 2g IV x1 for prophylaxis

• Local wound care

• Monitor for signs of infection or bleeding

Hypertension

• Start lisinopril given persistently elevated BP readings

Depression / anxiety / ADHD

• Continue home psychiatric medications once reconciled and confirmed

Disposition

• Admit to floor for supervised alcohol withdrawal and psychiatric evaluation

Hospital Checklist

• Diet: Regular

• DVT PPX: Lovenox

• Code Status: Full Code

• Medication Reconciliation: Complete

• Code Status Discussion: Discussed with patient

Progress Note

Date: 10/10/2025
Patient: Age/Sex: 57-year-old female
Code Status: Full Code

Interval Events / Subjective

Patient reports improvement in lethargy. Left heel pain and discoloration persist but stable. No new complaints. Mentation improved since holding gabapentin; now resumed. No fever, chills, chest pain, or shortness of breath. Awaiting vascular intervention scheduled for Monday, 10/13.

Objective

Vitals: Stable
Exam:

• General: Alert, oriented, no acute distress

• CV: Regular rate/rhythm

• Resp: Clear bilaterally

• Abdomen: Soft, non-tender, ileostomy present

• Extremities: R BKA well-healed; L heel with discoloration, mild tenderness, no erythema or drainage

Labs/Imaging:

• Glucose >600 on presentation, now improved

• Inflammatory markers slightly elevated

• XR: No osseous changes

• ABI/arterial US: Severe left lower extremity disease

Assessment / Plan

Left heel pain and discoloration
PAD, s/p R BKA (3/5/25)

• Consults: Podiatry, Nephrology, Vascular Surgery

• XR negative for osteomyelitis; inflammatory markers mildly elevated without leukocytosis or fever → low suspicion for infection

• Podiatry: No acute surgical intervention, no antibiotics needed

• Vascular: Severe disease; plan for peripheral angiogram Monday 10/13 (YSC)

  • Hold heparin SC on 10/13

• Pain management: Tylenol PRN

• WBAT to left foot, no dressing changes needed

Lethargy — resolved

• Likely medication-related (gabapentin).

• Gabapentin resumed as mentation improved.

• History of seizures; continues Depakote 250 mg daily.

HHS / Type 1 Diabetes Mellitus with hyperglycemia

• Endocrinology following

• Status post insulin drip

• Continue Tresiba 10 units daily

• Continue Lispro sliding scale

• No standing lispro at this time

• Home regimen: Lantus 17 units nightly, Lispro 6 units pre-meal + sliding scale (poor home control)

• If leaving AMA → resume home insulin regimen per Endo

• Continue Gabapentin 300 mg TID for neuropathic pain

CKD Stage 4

• Follows with Nephrology outpatient

• Creatinine at baseline (~2.0)

HTN / CAD s/p CABG / HFpEF

• Continue Amlodipine 10 mg daily

• Continue Aspirin and high-intensity statin

• Start Carvedilol 6.25 mg BID (home dose 25 mg BID, unclear adherence)

Seizure Disorder

• Continue Depakote 250 mg daily

Psychiatric (Bipolar / Depression / Anxiety)

• Continue Zoloft 50 mg daily

• Continue Trazodone 50 mg nightly

Medication Reconciliation Discrepancies

• Carvedilol 25 mg BID last filled May (30-day supply) – unclear adherence

• Iron started 5/2 (30 days) – patient reports adherence

• Advair Diskus last filled 5/2 (30 days) – taking as prescribed

• Comorbidities

• HFpEF (EF 72%, 8/27/24)

• CKD Stage 4 (GFR 15–29)

• Chronic Anemia

• History of COVID-19

Secondary Diagnoses during hospitalization:

• Diabetes with hyperglycemia

Hospital Checklist

• Diet: Cardiac Consistent Carbohydrate

• VTE Prophylaxis: Heparin 5000 units SC

• Med Rec: Complete

• Communication: RN, Case Management

• AM-PAC (RN/PT): 15 / —

• Expected Discharge: 10/11/25

• Disposition: Home with services

• Barriers: Pending vascular angiogram (10/13), glucose stabilization, wound evaluation

Date: 10/10/25
Service: Medicine

Subjective:
60-year-old female with PMHx of cystic fibrosis (no CFTR mutations, variants 9T/11TG and 7T/12TG, sweat chloride 26/25 and 30/35) with associated diarrhea, recurrent pneumonia, recurrent sinus infections, osteopenia, HTN, HLD, chronic pain/fibromyalgia on chronic opioids, iron deficiency anemia, and depression/anxiety on chronic benzodiazepines.

Presented on 10/5 with acute on chronic diarrhea and hypokalemia causing fatigue and palpitations. Hospital course complicated by hypotension secondary to fluid losses. Now with constipation following antidiarrheal use. Awaiting EGD.

Patient reports mild abdominal distention and discomfort but denies nausea, vomiting, or worsening pain. Passing gas. Tolerating current management.

Objective:

Vital Signs: Stable
General: Alert, oriented, no acute distress
Respiratory: Stable on room air
Abdomen: Mild distention, soft, non-tender, +BS
Extremities: No edema
I/O: Monitored

Labs:

• Electrolytes: improving

• Hypokalemia resolved

• Stool electrolytes pending

Imaging:

• CT A/P: likely ileus

Assessment & Plan:

1. Hypokalemia – resolved

   • Continue monitoring BMP, Mg, Phos

2. Hypotension / Hypovolemia – stable

   • Continue LR @ 100 cc/hr

   • Hold prazosin

3. Acute on chronic diarrhea, now constipation

   • LBM 10/8

   • Passing gas, no N/V

   • Stool electrolytes pending

   • Appreciate GI input (10/10):
     • EGD today for CSID testing
     • Continue Creon with meals/snacks
     • Hold home symbiotic, fiber, Lomotil

   • Discontinued Bactrim and cholestyramine

4. Cystic Fibrosis – stable on RA

   • Continue albuterol nebs q6h PRN

   • Hypertonic saline nebs if respiratory decompensation

   • Acapella device

5. Electrolyte / Fluid Management

   • Continue mag-ox daily

   • Hold oral KCl while on LR

   • Trend BMP, Mg, Phos

   • Monitor I/O closely

6. Chronic Conditions / Home Medications:

   • Psych: Abilify QD, bupropion QD, clonazepam QID, sertraline QD, Ambien PRN (hold prazosin)

   • HLD: Rosuvastatin QD

   • Chronic Pain: Fentanyl patch q72h, gabapentin TID, oxycodone PRN

   • Headache/Migraine: Fioricet PRN, rizatriptan PRN, Tylenol PRN

   • IDA: Ferrous gluconate QD

Comorbidities on Admission:

• Cystic fibrosis

• Chronic pain/fibromyalgia

• HTN, HLD

• Depression/anxiety

• IDA

Secondary Diagnoses During Hospitalization:

• Hypokalemia

• Hypocalcemia

• Hyponatremia

Admission Checklist:

• Code Status: Full Code

• Diet: Clears

• VTE Prophylaxis: Enoxaparin

• Medication Reconciliation: Completed by pharmacist

• AM-PAC (RN/PT): 21 / —

POC Communicated to: RN, Case Management
Discharge Readiness: Not medically ready
Expected Discharge: 2–3 days
Expected Disposition: Home

75 y.o. male

PMHx: 

HTN, HLD, T2DM, AFib on Eliquis, HFpEF, CVA c/b dysphagia and FTT s/p PEG, RA, AUD, diverticulitis s/p sigmoidectomy, cervical spondylosis, urinary retention, anxiety.
Course: Initially admitted 4/2025 for PEG site infection, prolonged hospitalization for conservatorship; c/b acute/subacute R cerebellar stroke, mild COVID, and delirium. Currently stable, pending safe discharge.

Plan:

• COE Attorney: Hilton; COP: Daughter Kelly.

• Appreciate PT evaluation — AMPAC 16.

• Pending T19 approval for LTC placement.

Cognitive Impairment / Subacute Cerebellar CVA / Delirium

• Geriatrics (signed off 5/22), Neurology (9/1) consulted.

• Nutrition: patient meeting ~90% of needs; cleared by SLP, G-tube removed 9/12.

• MRI brain: significant cerebral atrophy, poor neurological reserve, expect waxing/waning mentation.

• Avoid sedating medications.

• Continue:

  • Multivitamin daily

  • Thiamine 100 mg daily

  • Zyprexa 2.5 mg at 6 PM

  • Melatonin 6 mg nightly

  • Trazodone 25 mg PRN for insomnia/agitation

  • Ensure Plus TID

• Outpatient vascular neurology referral on discharge.

Dysphagia / PEG Site SSTI / FTT / Constipation

• Completed antibiotics course.

• Continue regular diet.

• Maintain bowel regimen as needed.

# HTN / HLD / HFpEF / Atrial Fibrillation

• Occasional asymptomatic bradycardia and PVCs noted on telemetry.

• Continue:

  • Carvedilol 3.125 mg BID

  • Eliquis

  • Jardiance

  • Statin

  • Entresto

  • Aldactone 25 mg daily

51 y.o. female 
PMHx: Chronic pain, bipolar disorder, morbid obesity, RLE DVT, prosthetic L hip joint infection on chronic minocycline suppression.
Admitted: 7/6 for fall and concern for prosthetic joint infection.
Course: IR aspirated left hip abscess on 10/3, culture grew E. coli; now febrile (10/10).

Plan

Left Hip Prosthetic Joint Infection

• Consults: ID, Orthopedics, IR.

• Imaging: US (9/26) showed left hip soft tissue collection; CT (9/22) with interval increase in size.

• Procedure: IR aspiration/drainage on 10/3.

  • Maintain drain to suction.

  • Flush with 5 cc NS BID.

  • Notify IR once drain <10 cc/day × 2 days for removal.

  • 10/8 drainage: 15 cc.

• Cultures: E. coli (10/3).

• Antibiotics: Continue ertapenem and minocycline while drain remains in place (per ID).

• Ortho: No evidence of true PJI; signed off.

• Precautions: Contact isolation (MDR E. coli).

• Pain regimen:

  • Flexeril 10 mg TID

  • Duloxetine 60 mg BID

  • Dilaudid 1 mg SQ q8h PRN (↓ from q8h to BID PRN)

  • Oxycodone 10–15 mg per pain scale

• PT signed off (9/16).

# New Fever (10/10)

• T 101.6°F overnight.

• Continue current antibiotics.

• Workup: RVP, UA, and CXR pending.

Right Femoral DVT / DOAC Failure

• Consult: Hematology (signed off 8/19).

• Found to have new femoral thrombus despite >30 days on Eliquis (8/14).

• Transitioned to warfarin after hematoma on lovenox.

• Warfarin dosing: Increased to 12 mg daily (per pharmacy).

• Follow-up: Repeat duplex in 3 months; outpatient hematology referral.

• Diet: Nutrition consult for warfarin education.

Bipolar Disorder / Chronic Pain / Opioid Dependence

• Continue:

  • Depakote 60 mg BID

  • Duloxetine 50 mg BID

  • Lexapro 5 mg AM

• Addiction medicine previously consulted (signed off 9/8); buprenorphine discussed but declined.

# Fungal Dermatitis / Intertrigo

• Continue nystatin.

# GERD

• Continue protonix.

Comorbidities

• Present on Admission: Chronic anemia (anemia of chronic disease).

• Developed During Stay: Hypocalcemia, thrombocytopenia.

Hospital Course / Orders

• Diet: Regular

• VTE PPx: Warfarin (12 mg daily)

• Expected Discharge Date: 10/11/25

• AM-PAC (RN/PT): 21 / 20

• Disposition: TBD, pending drain output; continue ertapenem until drain removal

• Code Status: Full