Cases for October 27th 2025

Case 1: 91-year-old female with Fever, Leukocytosis, and LLL Pneumonia

Situation
91-year-old female with no code: 

PMHx TAVR for AS, HTN, CAD, DM2 (neuropathy/retinopathy), CKD stage 3, PVD and prior CVA presents from home after fever to 103°F, malaise and lethargy. No cough, N/V, or SOB. In ED: WBC 24.7, Procal 0.28, Na 130, CXR shows LLL infiltrate. Started on ceftriaxone + doxycycline.

Background
Recent hospitalization 9/20–9/22 for acute diarrhea. Lives with daughter. Never smoker. Allergic to oxycodone, hydrocodone, and phenobarbital. On RA with stable hemodynamics. No focal deficits. CXR suggests possible basilar pneumonitis/aspiration vs CAP.

Assessment

• LLL Pneumonia – likely CAP vs aspiration. WBC 24, neutrophil-predominant, fever, +procal, CXR consistent.

• Rule out bacteremia / UTI – blood cultures in progress, no growth to date.

• Hyponatremia (Na 130) – likely hypovolemic vs inflammatory ADH response.

• CKD Stage 3 – Cr 1.14, eGFR 45.

• Anemia (Hgb 9.3) – chronic vs inflammation. HDS, no evidence of bleeding.

• CAD/HTN s/p TAVR – stable on home regimen.

• Depression – Zoloft planned.

• At risk for DVT – elderly, infection, decreased mobility.

Plan (with Rationales)

Problem	Plan	Rationale
LLL Pneumonia / Leukocytosis	Continue ceftriaxone + doxy; obtain urine strep/legionella antigen, sputum culture if able; trend CBC; incentive spirometry	Covers typical + atypical CAP; supports diagnostic clarity; lung expansion to prevent worsening atelectasis
Rule out bacteremia/UTI	Monitor blood cultures, obtain UA/urine cx	Fever with leukocytosis—must exclude additional source
Hyponatremia (Na 130)	Monitor BMP; gentle fluids if hypovolemic	Prevent worsening sodium drops and delirium
CKD Stage 3	Avoid nephrotoxins; renally dose meds; trend BMP	Reduce AKI risk in infection and elderly
CAD/HTN s/p TAVR	Continue diltiazem, losartan, Plavix, statin	Maintain cardiac stability and prevent ischemic events
Depression	Start Sertraline as planned	Stabilize mood; avoid untreated depression in elderly
Anemia	Monitor CBC; no transfusion unless symptomatic or Hgb <7	Likely anemia of chronic disease/inflammation
DVT PPX	Heparin SQ	High VTE risk with infection and immobility
Fever / Comfort	Tylenol PRN, maintain hydration, pulmonary hygiene	Prevent worsening metabolic demand and delirium
Code Status	Confirm with daughter in AM	Ensure clarity of goals of care in 91 y/o

CASE 2: 73-year-old Female (HFrEF, CKD4, Hypoxia, AMS)

SBAR

Situation:
73-year-old female with HFrEF (35–40%), CKD4, OSA (CPAP-nonadherent), obesity, and recent hypoxic respiratory failure now stabilized on 4L NC. Respiratory status improving, but intermittent altered mental status persists.

Background:
PMH significant for NICM, ICD, LBBB, prior CVA, CKD4, hypothyroidism, chronic diarrhea, recent shingles, and DRESS history. Being treated with moxifloxacin. Previously hallucinating and hypoxic to 89% on RA. Now A&O×4 but intermittently confused and requires reassurance. Mobility markedly limited; PureWick in place. On bedrest with decubiti risk.

Assessment:
Breath sounds diminished; on 4L NC without distress. Vitals stable. Neuro: improving but fluctuating mentation — multifactorial risk (hypoxia, infection, metabolic, polypharmacy, uremia). Skin: high risk for breakdown. Renal disease + heart failure increases risk for volume overload, pulmonary edema, and delirium.

Recommendation / Plan:
– Continue O₂ wean as tolerated, goal SpO₂ ≥92%
– Diuresis/volume management per team to optimize preload/afterload
– Delirium precautions + neuro checks
– Skin protection + mobility plan (turn q2h)
– Strict I/O, daily weights, renal dose meds
– Monitor QT (moxifloxacin), electrolytes, renal function

PATHOPHYSIOLOGY (High Yield)

Hypoxia + AMS in HFrEF + CKD: poor cardiac output → pulmonary congestion + impaired gas exchange. CKD reduces toxin clearance → uremic encephalopathy risk. Hypoxia + inflammation + metabolic derangements worsen cognition and cause delirium.

PRIORITIZED INTERVENTIONS WITH RATIONALES

Intervention	Rationale
Titrate O₂ to maintain SpO₂ ≥92%	Prevent hypoxic encephalopathy and reduce cardiac workload
Daily weights, strict I/O, monitor edema and lung sounds	Assess volume overload in HF/CKD
Cluster care, reorientation, lights on during day, minimize nighttime interruptions	Reduces delirium severity
Neuro checks q4h	Detect changes in mental status early
QT and electrolyte monitoring (K, Mg)	Fluoroquinolones ↑ QT risk and arrhythmia in HF
Turn q2h, moisture barrier, pressure-relief mattress	Prevent skin breakdown/decubiti
PT/OT eval; gradual mobility	Prevent deconditioning and improve respiratory mechanics
Renal-dose medications and avoid nephrotoxins	CKD4 = high AKI vulnerability

EXPECTED OUTCOMES

• SpO₂ ≥92% on decreasing oxygen support

• Stable mentation at baseline orientation

• No worsening edema, crackles, or weight gain

• Skin intact, no ulcer progression

• HR/rhythm stable, electrolytes within target range

CASE 3 — 58-year-old Male (ESRD on HD, Hypertensive Urgency, SOB/Chest Tightness)

SBAR

Situation:
58-year-old male with ESRD on HD, admitted for severe hypertension (BP >200/100) with SOB and chest tightness. Now A&O×4, breathing comfortably on room air, and completed HD.

Background:
PMH ESRD (2/2 diabetic nephropathy + FSGS), CAD s/p PCI, NSTEMI history, T2DM. On multiple antihypertensives and dual antiplatelet therapy. Electrolyte shifts and fluid retention increase risk for pulmonary edema, arrhythmias, and recurrent hypertensive crises.

Assessment:
Stable on RA, no acute complaints. However, ESRD + CAD = very high risk for afterload stress, flash pulmonary edema, and arrhythmia. BP remains primary issue requiring tight control and fluid management.

Recommendation / Plan:
– Continue scheduled antihypertensives and evaluate need for up-titration
– Post-HD weight, I/O, electrolytes
– Telemetry for ischemia/arrhythmias
– Low-sodium renal diet, daily BP trending
– Monitor chest pain, SOB, neuro changes

PATHOPHYSIOLOGY (High Yield)

In ESRD, the kidneys cannot excrete sodium or fluid → ↑ intravascular volume. RAAS and sympathetic tone remain overactivated → severe vasoconstriction and afterload → hypertensive crisis. CAD worsens oxygen supply-demand mismatch → chest pain/SOB.

PRIORITIZED INTERVENTIONS WITH RATIONALES

Intervention	Rationale
Trend BP q4h and after meds/HD	Detect rebound hypertension early
Telemetry monitoring	CAD + hypertension = high arrhythmia/ischemia risk
Post-HD weight and strict I/O	Determines volume removal efficacy
Low-sodium, fluid-restricted renal diet	Reduces preload and BP
Monitor K, Mg, Ca closely	ESRD dysregulates electrolytes → fatal arrhythmias
PRN antihypertensives per parameters	Prevent hypertensive emergency
Educate on adherence to HD and sodium restriction	Prevent recurrence

EXPECTED OUTCOMES

• BP controlled <140/90

• No SOB, chest pain, or pulmonary edema

• Stable electrolytes and rhythm

• Tolerates HD with target fluid removal