October 1st 2025: Progress Notes

1. CHF Patient:

Date: 9/29/25
Patient: 72 y/o male

PMH: 

CVA (residual left-sided weakness, aphasia), HTN, HLD, atrial fibrillation (on apixaban), seizure disorder, HFrEF, VT s/p ICD, LBBB, chronic hypercarbic respiratory failure, OHS, OSA, asthma.

Source of Admission: 

SNF → ED for abnormal arterial flow on outpatient vascular study.

Subjective / Interval Events:
Patient presented after outside radiology facility reported abnormal lower extremity arterial flow. Found to have right leg cellulitis with large pus-filled blister. Overnight, nursing reported desaturation requiring 2L NC O₂. Son updated at bedside; confirmed Full Code status.

Objective:

• General: Elderly male with chronic neuro deficits, currently alert but aphasic.

• Cardiac: Irregularly irregular rhythm, rate controlled.

• Pulmonary: Rales and wheezes bilaterally. CXR negative.

• Extremities: RLE cellulitis with large blister and surrounding erythema/calor. Open wounds noted. Palpable DP pulse on L foot; absent DP pulse R foot and absent PT pulses bilaterally.

• Neuro: Baseline aphasia and L-sided weakness from prior CVA.

Imaging / Studies:

• Outside bilateral arterial ultrasound (9/29/25): No flow to bilateral popliteal, posterior tibial, or dorsalis pedis arteries (occlusion vs slow flow). Radiologist recommended MRA.

• CXR: Negative for pneumonia.

Assessment / Plan

1. Lower Extremity Arterial Disease / Edema

• Abnormal arterial studies with concern for occlusion/low flow.

• Consult vascular surgery to review report and evaluate.

• Continue to monitor pulses closely.

2. RLE Cellulitis with Large Blister

• Start cefazolin empirically.

• Obtain MRSA PCR.

• Consult general surgery for I&D.

• Wound care consulted for management.

3. Acute Hypoxic Respiratory Failure on Chronic Hypercarbic Respiratory Failure, OHS, OSA, Asthma

• Required 2L NC overnight; attempt to wean this AM.

• Bilateral rales/wheezes, likely volume overload + mild asthma exacerbation.

• CXR negative, afebrile, no leukocytosis. No pneumonia at present.

• s/p 80 mg IV Lasix at 0700.

• Daily weights, strict I/Os.

• Resume home Symbicort BID and DuoNebs q6h.

• Hold prednisone for now while optimizing diuresis and inhaler regimen.

4. HFrEF / Hyperlipidemia

• Appears volume overloaded.

• Hold PO Lasix 40 mg BID; continue IV diuresis and titrate.

• Continue home carvedilol 3.125 mg BID, Entresto 24/26 BID.

• Continue spironolactone 12.5 mg Tues/Thurs/Sat (hold if SBP < 90).

• Sub rosuvastatin 5 mg daily for home statin.

5. Atrial Fibrillation

• Rate controlled.

• Continue apixaban 5 mg BID.

• Continue digoxin 125 mcg daily.

• Check digoxin level.

6. Seizure Disorder

• Continue levetiracetam 500 mg BID.

• Maintain seizure precautions.

Other Orders / Information

• Diet: Regular.

• VTE PPx: Apixaban (home).

• Medication Reconciliation: Pending pharmacist review; provider reconciled with SNF W-10.

• Family Communication: Son updated, confirmed Full Code status.

• Discharge Planning: Expected disposition to Long Term Care.

• Functional Assessment: AM-PAC pending (RN/PT).

2. Syncopal Patient:

Progress Note
Date: 10/1/25
Patient: 98 y/o male
PMH: Presbycusis (hearing aids), polymyalgia (on prednisone), HLD, CKD3a, lung cancer, lymphoma, hypothyroidism, anemia of chronic disease.

Source of Admission: ED with dizziness and presyncope.

Subjective / Interval Events:
Patient presented with 1-day history of dizziness and presyncope. No loss of consciousness, prodrome, seizures, or new neurological deficits. No chest pain, dyspnea, or cough. Denies tinnitus or worsening hearing loss. Reports persistent left shoulder pain from prior fracture.

Objective:

• General: AOx4, hard of hearing, communicates with aids.

• Neuro: No new deficits, gait stable.

• Cardiac: NSR on EKG, no ischemic changes, troponin peaked at 27.

• Pulmonary: On room air, saturating well.

• MSK: Limited ROM and pain at left shoulder (fracture 8/2025).

• Imaging: CT head and CTA neck – no acute findings.

• Labs: D-dimer normal, glucose normal.

• Studies ordered: Orthostatic vitals, telemetry, TTE.

Assessment & Plan

1. Dizziness / Presyncope
Likely orthostatic or vasovagal. Arrhythmia and structural causes under evaluation. Central cause less likely (no deficits, normal head imaging).

• Orthostatic vitals pending.

• Telemetry monitoring.

• TTE ordered.

• Stop troponin trend (peaked).

• Supportive measures: 1L LR slow infusion, rise slowly from supine, compression stockings, HOB > 30°.

• PT ordered.

• Daily glucose checks.

2. Troponin Elevation (demand ischemia)

• Asymptomatic, no ischemic changes on EKG.

• Troponin peaked at 27.

• Discontinue further trending.

3. Left Shoulder Fracture (Aug 2025, managed conservatively)
Persistent pain and decreased ROM.

• Pain regimen:

  • Tylenol 650mg PO q6h (mild)

  • Ketorolac 15mg IV q6h (moderate)

  • Oxycodone 2.5mg PO q4h (severe)

• Continue PT/OT for mobility and strength.

4. Presbycusis

• Reports hearing aids may run out of battery overnight.

• Attempted to contact wife (VM left) and Charter Senior Living. Wife expected at bedside.

• Day team to follow up for replacement batteries.

• Will use written communication if needed.

Chronic Problems

• Anemia of chronic disease: Stable Hb, continue to monitor.

• Polymyalgia rheumatica: Continue prednisone 1mg PO daily.

• Hyperlipidemia: Not on statin; lipid panel in AM.

• CKD3a: GFR currently stable; continue to monitor.

• Hypothyroidism: Continue levothyroxine 100mcg PO daily.

• Lung cancer & lymphoma: Outpatient follow-up.

Bundle / General Care

• Code Status: Full Code

• Activity: As tolerated

• Diet: Cardiac

• VTE ppx: Enoxaparin 40mg SQ daily

• GI ppx: Not indicated

• Bowel regimen: None

• Lines/Devices: PIV

• PT/OT: Ordered

• Wound Care: Not indicated

• Disposition: Observation

• Barrier to Discharge: Completion of acute evaluation

Current Medications

• Vitamin D 100mg PO daily

• Prednisone 1mg PO daily

• Levothyroxine 100mcg PO daily

• Enoxaparin 40mg SQ daily 

3. Abdominal Pain Patient 

Date: 10/1/25
Patient: 59 y/o female
PMH: Developmental delay, HTN, recurrent DVT/PE (on warfarin; hx apixaban failure), chronic exotropia/diplopia, ataxia, orthostatic hypotension (on midodrine), T2DM, neuropathy, OSA (not on CPAP), frequent falls.
Reason for Admission: Abdominal pain, diarrhea, dizziness, nausea.

Subjective / Interval Events:
Patient reports ongoing abdominal pain and diarrhea. Notes mild shortness of breath with productive cough (green phlegm). Denies dysuria but reports suprapubic tenderness. Denies chest pain, fevers, or chills. Endorses dizziness.

Objective:

• General: AOx4, pleasant, mild baseline intellectual disability.

• Neuro/MSK: Generalized weakness, baseline spasticity, requires 1x assist to bedside commode.

• Pulmonary: Mild wheezing, increased cough, room air.

• Cardiac: Stable, no acute ischemia on ECG.

• Abdomen: Mild suprapubic tenderness. No rebound/guarding.

• GU: UA with pyuria.

• Skin: Gluteal cleft fissure cleansed, left OTA. Skin otherwise intact.

• Lines: RFA PIV, flushed, CDI, saline locked.

Imaging:

• CT Abdomen/Pelvis w/ IV contrast (10/1/25):

  • No acute intraabdominal pathology.

  • Hyperdense material in vaginal vault → correlate with exam.

  • Dependent opacities at lung bases, L > R (atelectasis vs aspiration).

  • Urinary bladder wall thickening.

  • Other organs unremarkable.

Labs:

• C. Diff negative.

• INR 3.6.

• Glucose normal.

Assessment / Plan

1. Acute Abdominal Pain with Diarrhea
Likely iatrogenic diarrhea (Linzess use, polypharmacy). CT negative. C. diff negative.

• Monitor stools, repeat stool testing if febrile or worsening.

• Pain control as needed.

• Consider GI consult if persistent.

2. Shortness of Breath / Wheezing
CT suggests atelectasis vs aspiration. Cough with green sputum. On room air.

• RVP ordered.

• Start albuterol nebs.

• Consider steroids if wheezing persists.

3. Pyuria / Suprapubic Tenderness
UA positive for pyuria, no dysuria.

• Start ceftriaxone (previously tolerated).

• Monitor for UTI symptoms.

4. Dizziness / Hypotension
Likely secondary to diarrhea and volume depletion. Received 3L NS in ED.

• Additional fluids PRN.

• Resume midodrine.

• Monitor orthostatics.

5. Hyperdense Material in Vaginal Vault
Unclear etiology. Not visualized on ED exam. Reports suprapubic pain.

• Consider pelvic US or speculum exam.

6. DVT/PE on Warfarin
Therapeutic but supratherapeutic INR (3.6).

• Hold warfarin today.

• Resume 12.5mg daily starting tomorrow.

• Daily INR monitoring.

Chronic Conditions:

• Polymyalgia: Continue prednisone 1mg daily.

• T2DM: On cardiac carb-controlled diet. Daily glucose checks.

• OSA: Not on CPAP. Monitor overnight.

• Neuropathy/Ataxia: Baseline. PT/OT ordered.

• HTN: Monitor.

General Care / Bundle

• Code Status: Full

• Diet: Cardiac / Carb Controlled

• Activity: As tolerated, with assistance

• VTE PPx: Warfarin (held today; see plan above)

• GI PPx: Not indicated

• Lines/Devices: RFA PIV, saline locked

• Wound Care: Gluteal cleft fissure OTA, continue local care

• PT/OT: Ordered

• Disposition: Observation

• Barriers to DC: Ongoing evaluation of abdominal pain/diarrhea, workup of SOB/UTI

Current Medications

• Prednisone 1mg PO daily

• Vitamin D 100mg PO daily

• Warfarin (held today, resume tomorrow 12.5mg daily; variable schedule)

• Midodrine (resume)

• Ceftriaxone (new)

• Albuterol nebs (new PRN)

Patient with Failure to Thrive 

Date: 10/1/25
Patient: 77 y/o female
PMH: Cognitive impairment, HTN, HLD, morbid obesity (BMI 34), thyroid cancer s/p thyroidectomy, hypothyroidism, MDD/anxiety, recurrent UTIs, recent admissions for FTT, recent fall (d/c 9/25).

Presentation: Returned to ED with generalized weakness, inability to get out of bed, poor PO intake. In ED: VSS, mild hypernatremia, UA positive. Received IV fluids and ceftriaxone; admitted for further management.

Objective:

• AOx4

• On room air

• Foley catheter in place

• VSS

• Appears weak, poor oral intake reported

Assessment & Plan

1. Generalized Weakness / Poor Appetite / Mild Hypernatremia / FTT

• Continue D5 ½ NS at 75cc/hr

• Repeat BMP

• Orthostatic vitals ordered

• Maintain fall precautions

• PT evaluation for mobility/placement

• Anticipate need for SNF/rehab placement

2. Urinary Retention s/p Foley / Suspected UTI

• Foley exchanged in ED

• UA: cloudy, concerning for UTI

• Follow-up urine culture

• Continue ceftriaxone

3. Hyperlipidemia

• Continue home statin

4. Thyroid Cancer s/p Thyroidectomy / Hypothyroidism

• Recent outpatient labs concerning for hyperthyroidism → levothyroxine dose decreased

• Repeat TFTs this admission

• Continue levothyroxine 100 mcg daily for now

5. Constipation / Abdominal Pain

• Last BM 3 days ago

• Obtain AXR

• Continue bowel regimen

6. MDD / Anxiety / Cognitive Impairment

• Continue home regimen: aripiprazole, duloxetine, mirtazapine

• Continue clonazepam 1 mg daily + 0.5 mg QHS, 0.5 mg PRN BID

General Orders

• Diet: Cardiac

• VTE ppx: Lovenox

• Code Status: DNR/DNI

• Disposition: Pending clinical improvement, likely SNF placement

• Medication reconciliation: Based on most recent discharge summary