CLINICAL REPORT 2 Years Retro

Case 273B2

Patient: 79M, former police chief
PMHx: Hypertension, hyperlipidemia, diabetes mellitus (NIDDM II), solitary right kidney with CKD stage 3, obesity, asthma

Presentation: Admitted with left tibial plateau fracture

Problem List & Plan

1. Tibial plateau fracture (acute)

   • Ortho following; will monitor with Q2 week x-rays to assess healing/displacement

   • Possible need for surgical treatment if non-op management fails

   • Pain control as needed

   • PT for mobility; LLE NWB, evaluate tolerance with crutches

   • Stable for discharge to Acute Rehab 

2. AKI on CKD with solitary kidney

   • Cr trend 1.6 → 1.5 → 1.7 → 1.8, rising BUN

   • IVF 500 cc bolus

   • Avoid nephrotoxins/NSAIDs

   • Nephrology following

3. Hyponatremia (resolved)

4. HTN/HLD – Continue irbesartan, chlorthalidone, rosuvastatin

5. NIDDM II – F/S ACHS, SSI; continue glipizide, Actoplus Met

6. Asthma – Continue Flovent

7. Obesity – Monitor

Other: PT/OT/SW eval, GI/DVT prophylaxis

Home Medications: Chlorthalidone, Metoprolol, Irbesartan, Glipizide, Actoplus Met, Rosuvastatin, Aspirin, Flovent, Allopurinol, Fish oil, Ocuvite, Vaccination hx

Case 275B1

Patient: 80F
PMHx: HTN, HLD, atrial flutter (on Eliquis), DM, babesiosis (recent), frontal lobe brain mass

Problem List & Plan

1. Neoplasm of brain w/ mass effect & edema

   • Neurosurgery consult

   • Continue seizure prophylaxis & steroids

   • Neurochecks Q4h

   • MRI follow-up, biopsy planned

   • Pre-op evaluation

2. Hyponatremia (chronic, 2° hyperglycemia) – Monitor

3. Hyperglycemia – FS monitoring, A1c pending, adjust insulin

4. Weakness BLE (acute) – Likely tumor-related; PT as tolerated

5. Cerebral edema – Continue steroids

6. Anemia – Monitor H/H, transfuse as needed

7. BMI 29.0–29.9 – Lifestyle modifications

Medications: Apixaban, Atorvastatin, Metoprolol, Spironolactone, Glipizide, Insulin regular, Dexamethasone, Folic acid, Ca/Vit D supplements

Case 277B1

Patient: 60F
PMHx: Lung cancer (s/p wedge resection 2022), COPD/tobacco, ADHD, depression, HTN

Problem List & Plan

1. Intracranial hemorrhage (acute, L frontal)

   • Neurology following

   • Repeat CT/CTV

   • Monitor for seizures; EEG ongoing

2. Impaired ADLs (acute)

   • Rehab with PT/OT/SLP

   • Delirium precautions

3. Cerebral venous sinus thrombosis (acute) – Monitor

4. Syncope, ?seizure vs cardiogenic – Telemetry as needed

5. Prerenal azotemia, hypernatremia – IVF, monitor labs

6. Chronic COPD, lung cancer hx, HTN, depression, ADHD – Continue home meds

Psych/Behavioral: On Seroquel; monitor QTc; Haldol/olanzapine PRN agitation

DVT prophylaxis: Mechanical only

Case 289B1

Patient: 55M, unknown PMHx
Presentation: Found disoriented, combative, with constrictive jewelry injury to L ring finger; acute agitation

Problem List & Plan

1. Cellulitis of L ring finger + Enterococcus bacteremia

   • Augmentin PO 2 weeks

   • Topical wound care

   • Blood cultures NGTD

   • Refuses ring removal

2. Hyponatremia (chronic, Na 131; ?psychogenic polydipsia vs SIADH)

   • Strict 1L fluid restriction

   • Salt tabs BID

   • Lasix short course

   • Nephrology following

3. Psychiatric: agitation, psychosis, mood disorder, delirium

   • Constant observation

   • Telepsych: lacks capacity

   • Haldol 5 mg BID + Cogentin 1 mg BID; PRN Haldol/Ativan/Benadryl

Disposition: Transfer to inpatient psychiatry once medically stable (Na ≥135)

DVT prophylaxis: Lovenox

Case 293B2

Patient: 61F, spina bifida, stage IV CKD, ileal conduit, nephrolithiasis hx
Presentation: Rash post-amoxicillin, septic shock picture with pancolitis, UTI

Problem List & Plan

1. Sepsis (complicated UTI + pancolitis, possible MDR)

   • Broad-spectrum abx: Cefepime + Flagyl, Vanco adjusted per trough

   • Cultures pending

   • IV fluids, trend lactate, monitor hemodynamics

2. AKI on CKD IV – Likely ischemic ATN; monitor Cr/electrolytes

3. Metabolic acidosis (HAGMA, lactic + renal) – Monitor ABG

4. Drug rash (amoxicillin-related) – Avoid offending agent

5. Chronic comorbidities: Spina bifida, nephrolithiasis, ileal conduit, sacral decubitus ulcer

6. Functional quadriplegia/dysphagia – Palliative consult, feeding tube discussion

7. Goals of Care – Prognosis guarded; GOC discussions ongoing

Case 294B2

Patient: 30F, anxiety, on Klonopin/Adderall
Presentation: RUQ pain → cholelithiasis, biliary colic

Problem List & Plan

1. Biliary colic (acute)

   • Dilated CBD; possible stone passage

   • Trend LFTs/T. bili

   • Surgery + GI consulted

   • Pancultured

2. Elevated LFTs – Monitor closely

3. Anxiety – Continue meds as needed

4. DVT prophylaxis – SCDs

Surgical Progress: s/p lap chole, stable, tolerating PO, cleared for discharge with standard post-op instructions

Case 285B1

Patient: 61M, history professor
PMHx: Parkinson’s disease, migraines, liver cyst
Presentation: Erratic/paranoid behavior, possible med-related (pramipexole)

Problem List & Plan

1. Behavioral disturbance/paranoia (acute)

   • Psych consulted, no admission (unit full)

   • Wife reports worsening delusions, med noncompliance

   • Monitor safety; consider med adjustment

2. Parkinson’s disease – Possible med-induced symptoms; neuro follow-up

3. Psychosocial stressors – Supportive care, outpatient psych follow-up when feasible

Labs: CBC, CMP, UA unremarkable except Na 133, trace ketones, moderate hematuria.