Field Note October 31st 2025

Case 1: 

75-year-old male with COVID, T2DM, and generalized weakness

Situation

Patient admitted from ED for generalized weakness and fatigue; found with hypoglycemia and COVID positive with symptoms.

Background

PMH: Bullous pemphigoid (on MTX), prostate cancer, insulin-dependent T2DM, HTN.

Home meds: Novolog 18 U before meals, Tresiba 46 U daily.
Recent HbA1C 10.2% (poor control).

Assessment

• Weakness likely due to acute viral infection (COVID-19) and chronic hyperglycemia.

• No SOB or hypoxia (so no steroid indication). But intermittent coughs. 

• Glucose 230–300 mg/dL; persistent poor control.

• Complains of heartburn and indigestion; no alarm symptoms.

Recommendations

1. COVID-19 / General Weakness

• Symptomatic management and PT evaluation → supports recovery and preserves mobility.

• Paxlovid initiation → started because symptoms < 5 days and high-risk comorbidities; decreases risk of progression to severe disease.
  Rationale: Early antiviral use in high-risk adults lowers hospitalization risk.

2. Diabetes Management

• Repeat HbA1C → reassess long-term glycemic control.

• Reduce Tresiba to 35 U and add lispro 5 U with meals → prevents hypoglycemia while adjusting to inpatient caloric intake.

• MDSSI coverage → allows titration per glucose trends.
  Rationale: Tight glycemic monitoring during infection prevents further weakness and dehydration.

3. Heartburn / Indigestion

• Famotidine trial and Maalox PRN → symptomatic acid control.

• H. pylori stool antigen → rule out infection as a chronic cause.

• Follow-up with PCP and possible GI referral for EGD → appropriate if persistent symptoms.
  Rationale: GERD and gastritis are common in diabetics and long-term medication users.

4. BPH

• Continue Tamsulosin 0.8 mg daily → maintains urinary flow.

General Care

• Cardiac carb-consistent diet → supports glucose and BP control.

• DVT prophylaxis (enoxaparin) → immobility and infection increase clot risk.

• Stress ulcer prophylaxis (famotidine) → prevents GI bleeding during acute illness.

• PT evaluation → determines discharge readiness and functional status.

Case 2: 

82-year-old female with constipation, UTI, and recent stroke

Situation

Readmitted from rehab two days post-discharge for LLQ pain, found to have stool impaction and E. faecalis UTI.

Background

PMH: Dementia, aortic valve stenosis s/p replacement, atrial fibrillation (on dabigatran), mitral valve prolapse, HFpEF, CAD, recent stroke.

Assessment

• LLQ pain resolved with bowel regimen.

• Completed 3-day Ampicillin for E. faecalis cystitis.

• A-fib controlled with diltiazem/metoprolol.

• Mild delirium; no acute new deficits.

• Hypokalemia, hyponatremia noted.

Recommendations

1. Constipation Management

• Continue laxatives/enemas PRN → prevents recurrence and reduces delirium risk.
  Rationale: Constipation is a frequent cause of pain and confusion in elderly post-stroke patients.

2. UTI (E. faecalis)

• Complete antibiotic course → ensure bacterial clearance.
  Rationale: Prevents ascending infection and delirium exacerbation.

3. Atrial Fibrillation / Stroke History

• Continue dabigatran 150 mg BID, aspirin 81 mg, diltiazem, metoprolol, rosuvastatin → maintain rate control, anticoagulation, and vascular protection.

• Monitor HR, BP, hydration status → avoid hypotension and dehydration.
  Rationale: Stroke prevention and cardiac stabilization are key post-event.

4. Encephalopathy / Delirium

• Reorient frequently, optimize sleep and hydration, treat reversible causes (UTI, constipation, electrolyte imbalance).
  Rationale: Elderly with dementia and stroke history are highly prone to delirium; early recognition prevents decline.

5. Hypokalemia / Electrolyte disturbances

• Monitor BMP daily; replace K⁺/Mg²⁺ as needed.
  Rationale: Electrolyte imbalances worsen arrhythmias and confusion.

General Care

• Nutrition supplements and regular diet → prevent malnutrition.

• DVT prophylaxis maintained.

• PT/OT for rehab; discharge to acute rehab → improves post-stroke recovery.

Medication Review and Analysis

1. Aspirin 81 mg (Held)

Indication: Secondary prevention of cardiovascular or cerebrovascular events (MI, stroke).
MOA: Irreversibly inhibits COX-1 and COX-2 → decreases thromboxane A₂ → inhibits platelet aggregation.
Side effects:

• GI bleeding, peptic ulcers

• Bruising, increased bleeding risk (especially with anticoagulants)

• Renal impairment with chronic use
  Interactions:

• Heparin + Aspirin → additive bleeding risk

• NSAIDs may reduce aspirin’s antiplatelet effect

Rationale for Hold: Likely due to concurrent heparin infusion (high bleeding risk).

2. Calcium-Vitamin D (Held)

Indication: Osteoporosis prevention or correction of deficiency.
MOA:

• Calcium: bone mineralization

• Vitamin D: increases intestinal absorption of calcium and phosphate
  Side effects:

• Constipation

• Hypercalcemia (esp. if on thiazides)
  Interactions:

• Can decrease absorption of some antibiotics (e.g., ceftriaxone not affected IV, but oral quinolones/tetracyclines are)

• No significant issue in this regimen.
  Rationale for Hold: Possibly NPO status or to reduce pill burden.

3. Ceftriaxone 1 g IV Q24H

Indication: Empiric antibiotic for pneumonia, UTI, sepsis, etc.
MOA: 3rd-gen cephalosporin; inhibits bacterial cell wall synthesis.
Side effects:

• Diarrhea, biliary sludging

• Hypersensitivity (esp. with penicillin allergy)

• Rare: hemolysis, elevated LFTs
  Interactions:

• Calcium-containing solutions → precipitate risk (avoid co-admin with calcium IV products).

• Minimal interaction with heparin or cardiac meds.

4. Cyanocobalamin (Vitamin B12) (Held)

Indication: Treatment/prevention of B12 deficiency or pernicious anemia.
MOA: Cofactor for DNA synthesis and neurologic function.
Side effects:

• Rare: rash, mild diarrhea
  Interactions:

• Minimal clinically significant ones.
  Rationale for Hold: Non-urgent supplement; possibly held due to swallowing difficulty or NPO.

5. Dabigatran 75 mg BID (Held)

Indication: Stroke prevention in atrial fibrillation, DVT/PE prophylaxis.
MOA: Direct thrombin (Factor IIa) inhibitor.
Side effects:

• Major bleeding (GI, intracranial)

• Dyspepsia
  Interactions:

• Heparin + Dabigatran = contraindicated (massive bleeding risk)

• P-gp inhibitors (e.g., diltiazem) ↑ dabigatran levels
  Rationale for Hold: Overlapping anticoagulation with heparin → high bleeding risk.

6. Diltiazem CD 180 mg (Held)

Indication: Rate control in atrial fibrillation, hypertension, angina.
MOA: Calcium channel blocker; decreases AV nodal conduction.
Side effects:

• Bradycardia, hypotension

• Edema, constipation
  Interactions:

• Additive bradycardia with metoprolol

• Increases dabigatran levels (P-gp inhibition)
  Rationale for Hold: Likely due to low HR, hypotension, or IV rate control switch.

7. Furosemide 40 mg (Held)

Indication: CHF, pulmonary edema, volume overload.
MOA: Loop diuretic; inhibits Na⁺/K⁺/2Cl⁻ transporter in ascending loop of Henle → natriuresis.
Side effects:

• Hypokalemia, dehydration

• Ototoxicity (high doses)

• Hypotension
  Interactions:

• Can worsen renal function when combined with nephrotoxic drugs or dehydration

• Heparin → no direct interaction, but volume depletion can increase risk of thrombosis
  Rationale for Hold: Volume status concerns (low BP, risk of dehydration).

8. Metoprolol Tartrate 5 mg IV Q6H (Held)

Indication: Rate control (A-fib), hypertension, CHF, post-MI management.
MOA: Beta-1 blocker → reduces HR, BP, and myocardial oxygen demand.
Side effects:

• Bradycardia, hypotension

• Fatigue, confusion in elderly
  Interactions:

• Additive bradycardia with diltiazem

• Masks hypoglycemia symptoms if diabetic
  Rationale for Hold: Overlap with diltiazem or low BP/HR.

9. Multivitamin with Folic Acid (Held)

Indication: Nutritional support, anemia prevention.
MOA: Vitamin replacement for metabolism and RBC synthesis.
Side effects: Minimal.
Interactions: None significant.

10. Rosuvastatin 10 mg (Held)

Indication: Hyperlipidemia, ASCVD prevention.
MOA: HMG-CoA reductase inhibitor → lowers LDL and triglycerides.
Side effects:

• Myopathy, rhabdomyolysis

• Liver enzyme elevation
  Interactions:

• Diltiazem can increase statin levels → myopathy risk

• Caution in elderly, renal impairment
  Rationale for Hold: Transient LFT issues, infection, or polypharmacy risk.

11. Heparin Infusion (Active)

Indication: Anticoagulation for atrial fibrillation, DVT/PE, or bridging therapy.
MOA: Enhances antithrombin III → inhibits thrombin and Factor Xa.
Side effects:

• Major bleeding

• Heparin-induced thrombocytopenia (HIT)
  Interactions:

• With aspirin or dabigatran → additive bleeding

• With ceftriaxone → minor bleeding risk (platelet inhibition)
  Monitoring: aPTT, platelets, bleeding signs.

High-Risk Interactions and Cautions

Combination	Risk	Mechanism / Concern
Heparin + Aspirin	🚨 High bleeding risk	Dual anticoagulant effect
Heparin + Dabigatran	🚨 Contraindicated	Additive anticoagulation
Diltiazem + Metoprolol	⚠️ Bradycardia, heart block	AV nodal suppression
Diltiazem + Dabigatran	⚠️ Increased dabigatran levels	P-gp inhibition
Diltiazem + Rosuvastatin	⚠️ Myopathy risk	Increased statin level
Furosemide + Elderly	⚠️ Dehydration, hypotension	Volume depletion
Ceftriaxone + Calcium (IV)	⚠️ Precipitate risk	Avoid co-administration

Summary Impression

This frail 83-year-old patient has polypharmacy with overlapping cardiovascular and anticoagulant therapies.
Most medications are appropriately held due to:

• High bleeding risk (heparin + other anticoagulants)

• Potential for bradycardia and hypotension (metoprolol + diltiazem)

• Renal and hepatic caution (statin, diuretic)

• Decreased oral tolerance (frailty, reduced participation)

Case 3: 

71-year-old male with COPD, A-fib, and diabetic foot infection

Situation

Admitted with fever and respiratory distress; found to have suspected LLE osteomyelitis and COPD exacerbation.

Background

PMH: COPD with chronic respiratory failure (2 L O₂, BiPAP at night), A-fib on apixaban, DM2, HTN, stroke history, chronic pain, fibromyalgia.

Assessment

• Left foot digital ulcers with exposed bone → likely osteomyelitis.

• Afebrile now, but elevated CRP.

• Cannot undergo MRI (non-compatible device).

• Stable respiratory status on home O₂ and BiPAP.

Recommendations

1. Diabetic Foot Wound / Suspected Osteomyelitis

• Continue cefazolin + metronidazole → broad coverage per diabetic foot pathway.

• Daily wound care (Betadine DSD) and offload both legs → prevents further tissue injury.

• Follow podiatry, vascular, and limb salvage team; angiography planned.
  Rationale: Multidisciplinary management is crucial to prevent amputation and systemic sepsis.

2. COPD Exacerbation / Chronic Respiratory Failure

• Continue O₂ 1–2 L and nocturnal BiPAP, inhaled budesonide, and scheduled bronchodilators.

• Completed steroid burst → reduced airway inflammation.
  Rationale: Prevents hypercapnia and supports baseline oxygenation.

3. Anticoagulation

• Hold apixaban per vascular request → minimize bleeding risk during angiography.
  Rationale: Balances thromboembolic risk versus procedural safety.

4. Cardiac and Volume Management

• Monitor BNP, resume torsemide as tolerated → treat HFpEF while avoiding dehydration.

5. Pancytopenia

• Continue monitoring CBC; no current evidence of marrow failure.
  Rationale: Infection and chronic disease may contribute; trending avoids missed progression.

General Care

• Clear liquid diet pre-procedure.

• DVT prophylaxis → apixaban or alternative per hold status.

• Monitor for hypokalemia, hypocalcemia → replace as indicated.

Case 4: 

63-year-old male with right-hand post-surgical infection

Situation

Presented with swelling and redness of the right hand after leaving AMA post-amputation for osteomyelitis and stopping antibiotics early.

Background

PMH: Uncontrolled T2DM, HTN, bipolar disorder, alcohol use disorder, prior osteomyelitis.
Surgery: Right middle finger distal phalanx amputation (this month).

Assessment

• Post-surgical wound infection due to poor antibiotic adherence.

• No systemic fever yet, but local inflammation and swelling suggest recurrence.

Recommendations

1. Infection Control

• Restart IV antibiotics per ID (Cephalexin IV, then Bactrim PO if sensitive).

• Wound cultures → confirm organism.

• Daily wound care and hand elevation.
  Rationale: Early reinitiation of therapy prevents spread to bone or sepsis.

2. Diabetes Management

• Optimize insulin regimen and monitor glucose → hyperglycemia delays wound healing.
  Rationale: Tight glucose control reduces infection recurrence.

3. Pain Management

• Tylenol PRN, avoid NSAIDs if renal function impaired.
  Rationale: Adequate analgesia promotes compliance and rest.

4. Psychiatric & Social Factors

• Address non-compliance and alcohol use with social work and psych consult.
  Rationale: Behavioral instability contributes to repeated AMA discharges.

General Care

• Monitor for systemic infection signs.

• Reinforce wound dressing and hygiene education.

Case 5: 

54-year-old female with PSUD and lumbosacral discitis/osteomyelitis

Situation

Admitted for bacteremia and spinal infection secondary to IVDU; under prolonged IV antibiotics.

Background

PMH: Polysubstance use disorder, Serratia marcescens bacteremia, L4–S1 discitis/osteomyelitis with epidural and psoas abscess, anemia, thrombocytosis.

Assessment

• On ceftriaxone 2 g IV daily (9/26–11/6).

• No neurological deficits; pain managed.

• TLSO brace when out of bed; neuro checks q8h.

• ID, neurosurgery, addiction medicine involved.

Recommendations

1. Infection / Antibiotic Therapy

• Continue ceftriaxone until 11/6 with weekly labs (CBC, BMP, LFTs, ESR, CRP).
  Rationale: Prolonged therapy required for vertebral osteomyelitis to prevent relapse.

• Repeat MRI 6–8 weeks post-therapy → assess healing and resolution.

2. Pain Management

• Tylenol, ibuprofen, flexeril, lidocaine patch, gabapentin.

• Suboxone for IVDU and pain control (declined dose increase).
  Rationale: Multimodal analgesia avoids opioids while addressing chronic pain.

3. Substance Use Disorder

• Continue suboxone and consider LAI buprenorphine at discharge.
  Rationale: Reduces relapse and improves adherence to medical therapy.

4. Anemia and Thrombocytosis

• Monitor CBC; consider iron after infection clears.
  Rationale: Anemia of chronic disease vs. mild iron deficiency likely; iron given after infection resolution to avoid bacterial proliferation.

5. Skin Care

• Hydrocortisone for eczema plaques → symptomatic relief..

6. Trichomonas Vaginitis

• Completed Flagyl course; test of cure ≥ 3 weeks post-therapy.

General Care

• Regular diet, DVT prophylaxis with Lovenox.

• Full code.

• Inpatient stay until antibiotic completion.