From Ronnie's Clinic

CASE 1: 

CHF Exacerbation with Acute Hypoxic Respiratory Failure & IPF

Situation:
83-year-old male with PMHx HTN, HLD, CAD s/p CABG, AFib on Xarelto, PPM, idiopathic pulmonary fibrosis. Admitted for CHF exacerbation with acute hypoxic respiratory failure due to missed Lasix at home for 5 days. Currently improving on 3L NC, BNP downtrending, weight decreasing.

Quick assessment

A&Ox4

SOB with exertion

Denies pain and discomfort

VSS

On 2L O2 via nasal canula

OOB to commode x1

Regular diet

Safety measures in place and intact.

No BM

Voiding via condom cath. 

B Background:

• Chronic HFpEF

• IPF exacerbation

• Hypokalemia acute

• Hyponatremia resolved

• Leukocytosis resolved

• Mild transaminitis resolved

• Microcytic anemia chronic, stable

A: Assessment:

• CHF exacerbation acute on chronic, improving

• Acute IPF exacerbation, improving with steroids

• Electrolytes monitored

• Hemodynamics stable

R: Recommendations (with rationales):

• IV Bumex 1 mg BID
  Rationale: Loop diuretics decrease pulmonary congestion and preload in CHF exacerbation.

• Daily weights, strict I&O
  Rationale: Monitors fluid status and effectiveness of diuresis.

• Fluid restriction 1.5L/day
  Rationale: Prevents further volume overload in CHF.

• Trend proBNP
  Rationale: Biomarker to guide CHF therapy and monitor improvement.

• Continue Jardiance 10 mg
  Rationale: SGLT2 inhibitor improves HF outcomes in chronic management.

• Pulmonology follow-up, Solumedrol 250 mg BID x3 days → Prednisone taper
  Rationale: Steroids reduce inflammation in acute IPF exacerbation.

• Incentive spirometer
  Rationale: Improves lung expansion, prevents atelectasis.

• Replete electrolytes as needed
  Rationale: Corrects hypokalemia to prevent arrhythmias.

• Continue Xarelto
  Rationale: Prevents thromboembolism in chronic AFib.

Brief Progress Note:
Patient improving on current CHF regimen. Oxygen requirements stable on 3L NC. Electrolytes being monitored and corrected. Cardiology and pulmonology recommendations implemented. Continue strict fluid management and daily weights. Anticipate continued improvement and potential discharge planning once euvolemic and stable.

CASE 2:

Aspiration Pneumonia / Healthcare-Associated Pneumonia

Situation:
43-year-old male developed fever 103°F, tachycardia, and leukocytosis (WBC 23.13) after bronchoscopy on 10/22. New left lung opacity on chest X-ray.

Quick assessment

A&Ox4

SOB with exertion

Denies pain and discomfort

VSS

On room air

Independent

Regular diet

Safety measures in place and intact.

No BM

Voiding using the bathroom. 

 Background:

• No prior pneumonia prior to bronchoscopy

• Meets sepsis criteria

• Differential: post-procedural pneumonia, aspiration, HAP, atelectasis

Assessment:

• Likely healthcare-associated pneumonia

• Early sepsis, vitals stable with supportive care

• Pending blood culture results

• Possible discharge

Recommendations (with rationales):

• Continue Zosyn initiated in ED
  Rationale: Broad-spectrum coverage for hospital-acquired Gram-negative and anaerobic organisms.

• Add Vancomycin
  Rationale: MRSA coverage due to positive nasal screen.

• Supportive care: IV fluids, antipyretics
  Rationale: Maintains perfusion and treats fever symptoms.

• Monitor blood cultures
  Rationale: Guides antibiotic de-escalation once organism identified.

• Pulmonology consult
  Rationale: Expert guidance for post-bronchoscopy complications.

• Consider fungal testing if no improvement
  Rationale: Ensures coverage for opportunistic pathogens if refractory.

Brief Progress Note:
Patient remains febrile but hemodynamically stable. Oxygenation adequate on room air. Blood cultures pending. Continue broad-spectrum antibiotics. Pulmonology recommendations followed. Plan to reassess after culture results and clinical response.

CASE 3:

Sepsis Secondary to UTI / Parotitis / URI

Situation:
81-year-old male with DM, HTN, PE, chronic hyponatremia, re-presented with altered mental status, fever, tachycardia, WBC 16, positive urinalysis.

Quick assessment

A&Ox2

SOB with exertion

Poor PO intact

On clear liquid diet

Denies pain and discomfort

VSS

On room air

Bed rest

Safety measures in place and intact.

Had incontinent BM

Voiding via condom cath. 

Background:

• Recent robotic cholecystectomy (10/10/25)

• History of ESBL E. coli UTI

• Rhino and enterovirus positive on RVP

• Right parotiditis/submandibular sialoadenitis

Assessment:

• Sepsis secondary to urinary source

• Moderate hemodynamic instability

• AKI on CKD

Recommendations (with rationales):

• Continue Flagyl + Zosyn
  Rationale: Broad-spectrum coverage for urinary and intra-abdominal pathogens.

• ID consult
  Rationale: Specialist guidance for ESBL organisms.

• Supportive IV fluids
  Rationale: Maintains perfusion and prevents further AKI.

• Urine culture follow-up
  Rationale: Confirms pathogen and guides targeted therapy.

• Parotid care: warm compresses, massage, oral hygiene
  Rationale: Reduces inflammation and prevents secondary infection.

• NPO cancelled after swallow evaluation
  Rationale: Reduces aspiration risk.

Brief Progress Note:
Patient febrile but clinically improving on antibiotics. Hemodynamically stable. Renal function monitored. ID recommendations followed. Oral care and supportive measures implemented. Continue monitoring vitals, labs, and culture results.

CASE 4:

Post-Operative Respiratory Distress (COPD/Asthma)

Situation:
75-year-old male post-shoulder surgery with mild respiratory distress and low oxygen saturation since PACU. History of COPD and asthma.

Quick assessment

A&Ox4

SOB with exertion. O2 dropped after moving OOB. 

Reports pain and discomfort and received PRN medications

VSS

On 3L O2 via nasal canula

OOB to commode x1

Regular diet

Safety measures in place and intact.

No BM

Voiding via urinal at bedside. 

Background:

• Alert and oriented

• Mild bilateral expiratory wheezing

• No accessory muscle use or stridor

• Surgical site intact

Assessment:

• Acute on chronic respiratory acidosis

• Mild hypoxemia, likely V/Q mismatch from atelectasis, bronchospasm, or early pneumonia

• Postoperative hypoventilation possible

Recommendations (with rationales):

• Oxygen via NC, titrate as needed
  Rationale: Maintains SpO2 > 92% and supports gas exchange.

• DuoNeb treatments
  Rationale: Bronchodilator therapy reduces airway obstruction.

• Incentive spirometry & pulmonary hygiene
  Rationale: Prevents atelectasis and improves ventilation.

• Portable chest X-ray
  Rationale: Evaluate for early pneumonia or postoperative complications.

• Labs: CBC, Chem, PT/INR, D-dimer
  Rationale: Monitor for infection, coagulopathy, or inflammatory response.

• Repeat ABG if worsening
  Rationale: Tracks gas exchange and guides respiratory support adjustments.

Brief Progress Note:
The patient is A&Ox 4 and now stable on low-flow oxygen at 3L via NC. Mild wheezing noted on assessment. VSS. Labs within expected range for postoperative status. Will continue monitoring and titrate support as needed. Reported pain and received PRN pain medication with relief. Care plans reviewed with the patient. Safety measure in place and intact. 

CASE 5:

Pancreatic Cancer with Acute on Chronic Anemia, AKI, Diarrhea

Situation:
82-year-old male with pancreatic cancer, CKD4, DVT (off Xarelto due to GI bleed), post-pancreatectomy/splenectomy, presents with Hgb 6.4, fatigue, and diarrhea.

Background:

• Anemia chronic, Aranesp outpatient

• Mild hyperkalemia resolved

• Diarrhea acute

• Chronic metabolic acidosis

Assessment:

• Acute on chronic anemia, improved post 2U pRBC

• AKI on CKD4

• Diarrhea likely medication-induced

• Pain controlled, vitals stable

Quick assessment

• A&Ox4

  SOB with exertion

  Denies pain and discomfort

  VSS

  On room air

  Bedrest

  Regular diet with poor PO intake 

  Safety measures in place and intact.

  No BM but has colostomy

  Voiding using urinal at bedside

Recommendations (with rationales):

• Continue home metoprolol
  Rationale: Controls BP and heart rate, preventing cardiac strain.

• Nephrology and HemOnc consults
  Rationale: Specialist management for anemia, renal function, and oncologic care.

• Maintain euvolemia with NS 50 mL/hr
  Rationale: Supports perfusion and prevents fluid overload.

• Strict I/O, monitor ostomy output
  Rationale: Tracks fluid losses and guides management.

• Hold pancrelipase and stool softeners
  Rationale: Minimizes diarrhea triggers.

• Trial of loperamide as needed
  Rationale: Symptom control and patient comfort.

• Maintain MAP >65–70 mmHg
  Rationale: Ensures adequate renal perfusion and organ support.

Brief Progress Note:
Patient stabilized post-transfusion, Hgb now 12.5. AKI monitored, electrolytes within range. Diarrhea improving with medication adjustments. Continue oncologic and nephrology follow-up. Supportive care ongoing.

CASE 6:

Chronic Baseline Conditions

Distal Femur Periprosthetic Fracture

Situation:

89 y/o female

AOx2

2L O2 via NC

Bedrest

Patient presents with left knee pain and swelling. Imaging confirms periprosthetic distal femur fracture. Bed-bound baseline; family declined surgery at this time.

Background:

• Severe osteoporosis

• Non-ambulatory baseline

• History of anesthesia complications

Assessment:

• Acute periprosthetic distal femur fracture

• Pain controlled, neurovascular status intact

Recommendations (with rationales):

• Pain control as needed
  Rationale: Provides comfort and prevents sympathetic stress response.

• Knee immobilizer
  Rationale: Stabilizes fracture and prevents further injury.

• Orthopedic consultation
  Rationale: Confirms conservative management plan and monitors healing.

Brief Progress Note:
Patient is comfortable with immobilization. No neurovascular compromise. Conservative management continues with orthopedic guidance. Pain managed effectively. Monitoring ongoing.

Situation:
Patient is an 89-year-old female. Admitted today from home with Lewy body dementia, COPD, HTN, CHF, hypothyroid. Admitted for acute event (fracture or medical issue) as per prior cases.

Background:

• Cognitive baseline variable

• Stable pulmonary status on home oxygen

• Cardiac status stable

Assessment:

• Chronic baseline conditions stable

• Medications continued

 Recommendations (with rationales):

• Continue memantine 5 mg BID
  Rationale: Cognitive stabilization in Lewy body dementia.

• Continue quetiapine 50 mg qHS
  Rationale: Manages behavioral symptoms.

• Continue home COPD inhalers and oxygen
  Rationale: Maintains respiratory function and prevents exacerbation.

• Continue antihypertensives and CHF regimen
  Rationale: Prevents decompensation and volume overload.

• Continue levothyroxine
  Rationale: Maintains euthyroid state.

Brief Progress Note:

The patient’s a new admission to the unit. A&Ox4. Spanish speaking. On room air with no SOB. VSS. NPO at this time. OOB to bathroom independently. Care plans discussed with the patient. Safety measures in place and intact.