Clinical Cases For 10/26

CASE 1: 51-year-old Female 

Situation:
51-year-old female presented with acute weakness and paresthesias. Found to have hyponatremia, AG metabolic acidosis, and lactic acidosis, now resolved. Awaiting neurology consult and MRI brain/c-spine for further evaluation.

Background:
PMH: Class II obesity, CAD, HFrEF, HTN, HLD, chronic venous insufficiency, gastric bypass, opioid use disorder/chronic pain. CT head negative. Strength and sensation intact on exam. On chronic opioids and methadone. Mild conjunctivitis and chronic anemia.

Assessment:
A&Ox4, on room air, denies SOB. Strength grossly intact but reports subjective weakness. Na 133–135; lactate corrected with fluids; AGMA resolved. Abdomen distended but CT A/P negative. Hgb 8. Mild hypokalemia, being corrected. Stable cardiovascularly, lungs clear, euvolemic.

Recommendation and Plan (with rationale):

• Neurology consult + MRI brain/c-spine, to investigate central causes of weakness and paresthesias (stroke, demyelination, cord pathology).

• Neuro checks q4h — early detection of neuro decline.

• Continue high-dose Thiamine — prevents/treats Wernicke’s or nutritional neuropathy given gastric bypass and OUD history.

• Check Zinc, Copper, B6, Vit E, ESR/CRP, SPEP/UPEP, HIV, Treponema: to rule out metabolic, nutritional, inflammatory, autoimmune, infectious, and neuropathic causes.

• Repeat BMP in AM: trend sodium and electrolytes during correction.

• Hold further IV diuresis; restart home Lasix PO tomorrow: patient appears euvolemic; prevents hypotension and prerenal insult.

• Continue Amlodipine, Coreg, Losartan, Aldactone: maintains BP and guideline-directed therapy for HFrEF.

• Continue Methadone and PRN Dilaudid: prevents withdrawal and manages chronic pain until taper plan defined.

• Continue Miralax + Senna, bowel regimen for opioid-induced constipation and abdominal distention.

• Recheck LFTs, CBC, LFTs in AM: to monitor chronic abnormalities and anemia.

• Erythromycin eye ointment:  treats suspected conjunctivitis.

• Telemetry + Daily weights,  monitor HF status.

Clinical Progress Note:

Patient is A&Ox4, resting in bed, on room air without SOB, denies chest pain or acute discomfort. Reports mild generalized weakness but moves all extremities with intact sensation. VSS. Abdomen distended but soft and non-tender to touch. OOB with assistance ×1. Neuro checks ongoing every 4 hours. Electrolyte replacement provided as ordered. Safety precautions maintained. Care plan reviewed and patient verbalized understanding. Will continue to monitor patient closely.

CASE 2: 65-year-old Male

Situation:
65-year-old male presented with nausea, vomiting, and diarrhea since yesterday. Found to have AKI and hypomagnesemia, likely secondary to volume depletion.

Background:
PMH: HTN, HLD, T2DM, opioid use disorder (methadone), cocaine use, cannabis use, intestinal metaplasia of stomach.

Assessment:
A&Ox4, hypertensive in ED, denies SOB. Lungs clear, dry mucous membranes noted. AKI on labs, hypomagnesemia, NSR on EKG. No abdominal tenderness. Utox pending. Risk of CHS given cannabis use.

Recommendation: Plan (with rationale):

• s/p IV fluids, continue volume repletion PRN,  corrects prerenal azotemia from hypovolemia.

• Hold Lisinopril, ACE-Is worsen AKI by decreasing renal perfusion pressure.

• Recheck BMP in AM; if worsens, check urine lytes/FENa, distinguish prerenal vs intrinsic renal injury.

• Replete electrolytes, especially Mg: To prevents arrhythmias and supports renal recovery.

• Zofran PRN + Maalox + Protonix: antiemetic and GERD management to control triggers.

• If diarrhea recurs → C. diff / stool PCR:  rule out infectious causes.

• Check Utox: essential for cocaine/cannabis-related symptom correlation (CHS, sympathetic surge).

• Resume Norvasc; hold Coreg: avoid unopposed alpha stimulation in setting of recent cocaine use.

• Benzodiazepines if CP develops: first-line for cocaine-induced chest pain.

• Continue Methadone + CIWA + B1/Folate, prevents withdrawal and addresses nutritional risks.

• SSI + Continue Gabapentin glucose control and maintenance therapy.

• Continue ASA and statin: secondary prevention for HTN/HLD.

• DVT PPx: Heparin, prevents VTE due to decreased activity.

CASE 2: Progress Note

Patient is A&Ox4, on room air, no SOB, reports intermittent nausea but no emesis during shift. VSS except mild hypertension. IV fluids infusing as ordered. Electrolytes are being replaced. Abdomen soft, non-tender, bowel sounds present. Reported BM this morning. Voiding adequately. Safety education provided; patient verbalized understanding. Care plan updated. Will continue to monitor the patient closely and address renal function and symptoms accordingly.

CASE 3: 50-year-old Female, ESRD s/p DDKT

Situation:
50-year-old female with a kidney transplant (2020), CKD stage IV, T2DM with gastroparesis, and chronic anemia, who presented with nausea, vomiting, abdominal pain, colitis on imaging, and starvation ketosis, now resolved. Symptoms improving on antibiotics and supportive care.

Background:
PMH: ESRD → DDKT, CKD-4, HTN, NIDDM2 with gastroparesis, pancreatitis, chronic anemia. On tacrolimus, mycophenolate, and prednisone. Hypokalemia noted. Abdominal CT with colitis. Lactate WNL. S/p bicarb gtt for starvation ketosis.

Assessment:
A&Ox4, on room air, abdominal tenderness improving, tolerating PO with less nausea. Cr also improving (2.6 → 2.2). No diarrhea. On antibiotics and antiemetics. Electrolytes mildly abnormal but stable. HAGMA improving.

Recommendations / Plan (with rationale):

• Cefuroxime + Flagyl (7-day course): treats colitis and prevents infectious progression.

• Antiemetics (Zofran/Compazine): controls N/V to prevent fluid loss and aspiration.

• Switch to Oxycodone PO; limit IV Dilaudid-PO is safer, reduces risk of respiratory depression and dependency.

• Low-fat diet: reduces gastroparesis flare and pancreatic stimulation.

• Continue tacrolimus, mycophenolate, prednisone (daily tacro level),  prevents allograft rejection.

• 1L LR + hold bicarb drip: rehydration for prerenal AKI and anion gap closure.

• Daily CBC, BMP, Mg, Phos, Tacro level: trend renal function, rejection risk, and electrolyte status.

• Stool studies pending :rules out infectious colitis if symptoms recur.

• Monitor K+ :hypokalemia increases arrhythmia risk in CKD and transplant patients.

• Heparin for DVT PPx ,  reduced mobility + CKD increases VTE risk.

CASE 3: Progress Note

Patient is A&Ox4, on room air without SOB, reports improving abdominal pain and nausea, no emesis during shift. IV fluids infused as ordered. Transitioned to PO antibiotics and PO oxycodone with good effect. Abdomen soft, mild tenderness, positive bowel sounds. Voiding without difficulty. No BM reported today. VSS. Safety maintained. Care plan reviewed; patient verbalized understanding. Will continue to monitor renal function, pain, and GI symptoms closely.

CASE 4: 78-year-old Male, Dementia w/ Fall Risk

Situation:
78-year-old male admitted for weakness and near fall, now with acute delirium, agitation, urinary retention, and constipation. Family unable to care for him; requires placement planning.

Background:
PMH: Alzheimer’s dementia, HTN, HLD, T2DM, PVD, Gout. Hospital course complicated by agitation requiring restraints (now off), constipation, and urinary retention. On multiple psychotropics guided by Geriatrics.

Assessment:
Patient is A&Ox × baseline dementia, calmer today, improved agitation, out of restraints >24 hrs. Bladder scans ongoing. Multiple BMs after bowel regimen. VSS. Mild anemia. Mobility limited and requires assistance. High fall risk.

Recommendations / Plan (with rationale):

• PT eval + STR referral + CM/SW: patient unsafe at home; requires rehab and supervised care.

• Continue Seroquel, Trazodone, Remeron; PRNs available, treats agitation, stabilizes sleep–wake cycle, reduces delirium severity.

• Thiamine + Folic Acid: addresses nutritional deficiency risk and supports cognition.

• Bladder scans + straight cath PRN: prevents bladder damage and infection.

• Continue Miralax + Senna, repeat Dulcolax if needed, relieves constipation contributing to delirium and urinary retention.

• Hold HCTZ: reduces fall risk and prevents over-diuresis in elderly.

• Continue Atenolol, Diltiazem, Lisinopril, ASA, Statin: chronic disease control.

• Hold Metformin/Tradjenta -prevents hypoglycemia due to poor PO intake in delirium.

• Continue Allopurinol -prevents gout flare.

• Lovenox for DVT PPx- reduced mobility = high VTE risk.

CASE 4: Progress Note

Patient is calm and cooperative, A&Ox to self only (baseline dementia). On room air, with no SOB. VSS. No agitation noted this shift and no PRNs required. Bladder scans performed per protocol, voiding with intermittent catheterization. Abdomen soft with active bowel sounds; multiple BMs noted after bowel regimen. Safety precautions in place including bed alarm, close rounding, and fall bundle. Care plan reviewed and wife updated on phone today. Will continue to monitor mental status, elimination pattern, and safety needs.

Case 5

Situation
83-year-old female with extensive PMH (spina bifida, paraplegia, neurogenic bladder w/ chronic Foley, chronic sacral & heel pressure wounds, Factor V Leiden, h/o DVT, colostomy w/ stenosis, bladder tumor s/p resection, chronic anemia) presents with abdominal pain found to be duodenitis. Leukocytosis improving (21.2 → 11.4). Ongoing abdominal pain, but improved. On Flagyl, cefuroxime added for intra-abdominal coverage.

Background

• Wheelchair-bound, chronic Foley, colostomy, chronic wounds

• Tolerating diet, producing stool, no obstruction on CT, no N/V

• Hgb dropped from 10.7 → 9.1 (baseline 8–10), no bleeding or IVF

• AOx3, room air, Foley in place, incontinent of stool, regular diet. 

• Code: Full Code | DVT PPX: Enoxaparin

Assessment

• Duodenitis improving; abdominal pain persists but less severe.

• Leukocytosis improving on antibiotics

• Macrocytic anemia- stable near baseline

• Chronic wounds-continue wound regimen and supplements

• Hypothyroidism stable on levothyroxine

Recommendation / Plan

• Continue Flagyl + add Cefuroxime for intra-abdominal coverage; monitor leukocytosis and abdominal exam x 24 hrs

• Follow-up stool studies

• Tylenol PRN for pain

• Trend CBC for macrocytic anemia

• Continue levothyroxine, wound care, and vitamins

• Continue VTE ppx and cardiac diet

Progress Note (Objective)

Pt. AOx3, calm, on room air without respiratory distress. Regular diet tolerated, positive stool output via colostomy. Foley patent with clear yellow urine. Abdomen soft, mild tenderness, no N/V. Chronic sacral and heel wounds present-dressings clean, dry, intact. Hgb 9.1, WBC 11.4. Continued oral antibiotics. Fall and skin precautions in place. Will continue monitoring.

Interventions & Rationales (Care Plan Style)

Problem	Intervention	Rationale
Duodenitis / Infection	Continue Flagyl + add Cefuroxime; monitor WBC, stool, abdominal exam	Broadens coverage for intra-abdominal pathogens and prevents worsening infection
	Assess pain and administer Tylenol PRN	Controls pain and improves mobility and PO intake
Macrocytic Anemia	Trend CBC q24–48 hrs	Detects bleeding or bone marrow suppression
	Administer folic acid, B12	Supports RBC production in macrocytosis
Chronic Wounds	Reposition q2 hrs, wound care, Vit C + nutrition optimization	Improves perfusion and collagen healing; reduces pressure injury progression
Neurogenic Bladder / Foley	Foley care qshift; monitor output	Reduces CAUTI and maintains renal perfusion
DVT Prophylaxis	Enoxaparin + SCDs	Prevents thrombus in paraplegic patient with high VTE risk
Hypothyroidism	Continue levothyroxine AM on empty stomach	Maintains metabolic stability and med absorption

PLAN:

• Continue Flagyl + Cefuroxime

• Follow stool studies

• Tylenol PRN

• Trend CBC

• Continue levothyroxine 12.5

• Vitamin C, wound care

• VTE PPX: Enoxaparin

• Cardiac diet

• Full Code

Status Summary:

Improving duodenitis with resolving leukocytosis, stable vitals, tolerating diet, and no acute complications; continue antibiotics and monitoring.