Notes

Patient Report

Patient: 54-year-old male
Source of Arrival: EMS from SNF
Chief Complaint: Abdominal pain, inability to urinate, and constipation

History of Present Illness (HPI):
Patient is a 54-year-old gentleman with a past medical history of chronic constipation (multiple admissions for fecal impaction/stercoral colitis), type 2 diabetes, atrial fibrillation on apixaban, anxiety, CVA with residual deficits, hyperlipidemia, and BPH. He presents with 2 days of lower abdominal pain (6/10 in intensity) associated with nausea and vomiting. Patient reports no bowel movement and no urination since last night. He denies chest pain, shortness of breath, fever, or chills.

Emergency Department Findings:

• Abdominal ultrasound: >1L urinary retention

• Concern for fecal impaction noted by ED physician

• Kidney function: Unremarkable

• Foley catheter placed with symptomatic relief

• CT abdomen/pelvis ordered for confirmation of stercoral colitis

Physical Exam (pertinent):

• Alert and oriented ×4

• Abdominal pain localized to lower quadrants

• No acute distress otherwise noted

Assessment/Plan:

1. Acute urinary retention

   • Likely secondary to severe constipation exerting mechanical pressure on the bladder

   • Foley catheter in place

   • Awaiting CT abdomen/pelvis results

   • Continue bowel regimen: lactulose, MiraLax, senna (scheduled), bisacodyl suppository PRN

   • Plan for bisacodyl suppository + enema following CT results

   • Restarted home tamsulosin

2. Chronic constipation with recurrent fecal impaction / suspected stercoral colitis

   • Aggressive bowel regimen as above

   • Close monitoring for recurrent impaction

3. Mild thrombocytopenia

   • Chronic finding, no acute intervention required

4. Type 2 diabetes mellitus

   • Home: metformin (held inpatient)

   • Initiated: lispro sliding scale (low-dose)

   • Continue pregabalin

   • Monitor blood glucose with fingersticks

5. Anxiety disorder

   • Continue fluoxetine, alprazolam, and mirtazapine

6. Cerebrovascular accident (CVA) with residual deficits / Atrial fibrillation

   • Continue apixaban (Eliquis), aspirin, and rosuvastatin

7. Hyperlipidemia

   • Continue rosuvastatin

8. Hypotension

   • Continue midodrine

9. Gastroesophageal reflux disease (GERD)

• Continue famotidine

Patient: 66-year-old male
Past Medical History: Hypertension, hyperlipidemia, polysubstance use disorder (heroin, cocaine), previously on methadone maintenance, alcohol use disorder, tobacco use disorder (active smoker), possible COPD

Presentation:
Patient presented to the ED with unresponsiveness after reportedly ingesting liquid methadone and heroin. EMS administered naloxone in the field with subsequent return of consciousness. On arrival to the ED, patient was alert and oriented ×3, hemodynamically stable. Urine toxicology positive for cocaine, fentanyl, and methadone. He is admitted for closer monitoring and withdrawal management.

Plan:

1. Opioid Use Disorder / Suspected Methadone Overdose

   • Status post naloxone administration by EMS

   • Currently A&O ×3, hemodynamically stable

   • Monitor on telemetry

   • Serial EKGs

   • Urine toxicology positive for cocaine, fentanyl, methadone

   • Monitor for withdrawal with COWS protocol

   • Symptom management: ondansetron, acetaminophen, dicyclomine PRN

   • Clonidine per protocol

   • No concern for suicidal or homicidal ideation

   • Addiction Medicine consult in the morning

2. Alcohol Use Disorder

   • Monitor on CIWA protocol

   • Thiamine, folate, multivitamin daily

   • Diazepam per protocol based on CIWA scores

3. Hypertension / Hyperlipidemia

   • Previously on amlodipine and lisinopril; compliance unclear

   • Resume amlodipine

   • Statin continued

   • Unclear history of furosemide use—verify with pharmacy

4. Cough / Possible COPD

   • Chest X-ray ordered

   • Respiratory viral panel ordered

   • Guaifenesin PRN for cough

   • Albuterol PRN for shortness of breath/wheezing

   • Continue Symbicort

   • Consider outpatient PFTs

5. Tobacco Use Disorder

   • Nicotine patch provided

Additional Orders:

• Medication Reconciliation: To be verified with pharmacy in the morning (patient unable to recall home meds)

• Diet: Cardiac

• DVT Prophylaxis: Lovenox

• Code Status: Full

• Disposition: Pending clinical improvement

Patient: 72-year-old female
Past Medical History: Developmental delay, history of psychosis, hearing impairment, breast cancer s/p right mastectomy, asthma, pulmonary arterial hypertension, osteopenia, vitamin D deficiency, hypertension, hyperlipidemia, GERD, obesity (BMI 34)

Chief Complaint: Persistent right knee pain

History of Present Illness (HPI):
Patient presents for re-evaluation of ongoing right knee pain. She was initially evaluated on 9/20, when pain was attributed to a popliteal cyst. There is history of a possible slip in the shower, but her aide does not believe there has been any recent trauma. Pain has persisted despite conservative measures.

Imaging:

• X-ray: No osseous injury

• Ultrasound: Small suprapatellar effusion

Rheumatology: Attempted aspiration of effusion—unsuccessful

Assessment/Plan:

1. Acute Right Knee Pain – likely monoarthritis vs bursitis

   • Continue acetaminophen ATC

   • Trial toradol ATC × 24h

   • Ibuprofen given previously without much relief

   • PT evaluation: currently requires assist of 1 → would require STR if ongoing

   • Group home unable to accept patient if she requires assist of 1

   • Patient may not tolerate STR placement (developmental delay, hearing impairment)

   • Goal: Optimize pain control → repeat PT evaluation → attempt discharge home

2. Hypertension

   • Continue atenolol

3. Psychiatric history (psychosis/developmental delay)

   • Continue benztropine, mirtazapine, perphenazine

4. Pulmonary Arterial Hypertension

   • Continue furosemide 20/40 QOD

5. Asthma – no acute exacerbation

   • Continue montelukast

6. GERD

   • Continue famotidine

7. Hyperlipidemia

   • Continue statin

8. Obesity (BMI 34)

   • Ongoing management

9. Hypokalemia

   • No recent labs within past 24h

   • No treatment ordered at this time

Physical Exam / Nursing Notes:

• Neuro: Alert and oriented ×4. Communicates with ASL assistance, some verbal words.

• CV: Regular heart rate, not on telemetry.

• Resp: Breathing spontaneously on room air.

• GI: Abdomen soft, on chopped diet, able to swallow pills whole.

• GU: Continent, requires 1-person assist to bedside commode.

• Skin: Intact over pressure points, able to self-turn in bed.

• Mobility: Requires 1-person assist to pivot bed → chair/commode (Mobility Score: 14).

• Safety: Bed alarm in place, all safety precautions maintained.

• Isolation: Protective precautions in effect.

Disposition:

• Pending improvement in pain control and repeat PT evaluation to determine if patient can return to group home vs STR.