Progress Notes

S – Situation:

96 y.o. female from SNF with PMHx of dementia, HFpEF due to TTR cardiac amyloidosis, pulmonary hypertension, HTN, HLD, A-fib, SSS s/p PPM, CKD 3B, urinary retention with chronic Foley, gout, hypothyroidism, and DM.

Admitted on 10/8 for rhinovirus infection and HFpEF exacerbation. 

Patient is AOx1, on room air, bedrest, no code / DNR–DNI.
Currently c/o intermittent chest pain and altered mental status.

B – Background:
Recent CXR shows prominent interstitial markings and bibasilar opacities consistent with infection vs. pulmonary edema.
ProBNP elevated at 40,000 (prior ≤25,000), HS troponin 80→93→90 (no significant EKG changes).
Procalcitonin negative. RVP positive for rhinovirus. Weight up ~10 lbs (possibly inaccurate).
Urine culture growing Klebsiella, pan-sensitive.

Foley catheter in place for chronic urinary retention; I&O monitored strictly.
IV access: Left forearm #20G.

A – Assessment:

• Respiratory: On RA, no SOB. +JVD, +BLE edema → volume overload suspected.

• Cardiac: HFpEF exacerbation; hemodynamically stable.

• GU: Chronic Foley, pyuria present; UA difficult to interpret due to indwelling catheter.

• GI: BM today.

• Neuro: Dementia, AOx1 at baseline.

• Renal: CKD4, Cr stable at baseline.

• Skin: Intact.

• Mobility/Nutrition: Bedrest; 1:1 feeder; cardiac consistent carbohydrate diet.

• Mood: Calm; occasionally confused.

• Comorbidities:

  • Acute on chronic HFpEF (EF 55% on 7/10/2025)

  • Immunosuppressed due to chronic prednisone

  • Hypercoagulable state (A-fib)

  • PMH COVID

  • Secondary: Hypocalcemia

R – Recommendation / Plan:

1. Rhinovirus / HFpEF exacerbation:

   • Continue Hydralazine 50 mg

   • Resume home dose Bumex 2 mg PO BID

   • Metolazone 5 mg BID today to augment diuresis

   • Monitor lytes, Cr, I/O, daily weight

2. Pyuria / Chronic Foley:

   • Continue Foley care

   • Follow up urine cultures

   • Started on Ceftriaxone 10/11 for Klebsiella (pan-sensitive)

3. CKD4:

   • Monitor renal function closely with diuresis

4. Gout:

   • Continue prednisone 5 mg daily

   • Continue allopurinol

5. Hypothyroidism:

   • Continue levothyroxine

6. Mood disorder:

   • Continue mirtazapine

7. Other:

   • VTE prophylaxis: apixaban (Eliquis) 2.5 mg

   • Diet: Cardiac consistent carbohydrate

   • Continue to monitor for respiratory distress, worsening edema, or chest discomfort.

   • Maintain bedrest, assist with ADLs, ensure safety measures.

78 y.o. male with PMHx s/f dementia, CAD, COPD, HTN, and severe malnutrition, who presented with progressive dementia and behavioral disturbances, initially felt to be secondary to UTI, now s/p 5-day course of antibiotics. Currently awaiting conservatorship (of finance) and T19.

Plan:

• # Dementia w/ Behavioral Disturbance

  • Continue olanzapine 5 mg at 6 pm (with melatonin and trazodone 50 mg at 8 pm)

  • Trazodone 25 mg TID PRN for agitation

• # Fungal Rash (hips)

  • Continue clotrimazole BID x 2 weeks

Chronic/Stable Issues:

• CAD – Continue aspirin, statin

• Severe malnutrition – Continue thiamine, folic acid, MV, Ensure TID

• COPD – Continue Stiolto

• Orthostatic hypotension – Continue midodrine 2.5 mg TID (consider holding; monitor BP)

• BPH – Continue Flomax

Comorbidities on Admission: Chronic anemia
Additional Findings: Patient reports food insecurity

Diet: Regular, with nutritional supplements
VTE PPx: Enoxaparin 40 mg SC daily
Medication Reconciliation: Partially complete
Communication: RN and Case Management

Discharge Readiness:

• Expected Discharge Date: 10/28/25

• AM-PAC (RN/PT): 15 / 16

• Expected Disposition: Long-Term Care

• Barrier(s): Pending T19 approval

• Code Status: Full Code

Patient 2:
89 y.o. female with PMHx s/f dementia c/b behavioral disturbance, HTN/HLD, HFrEF, CKD3b, TIA, and recurrent UTIs, who presented with increased confusion, agitation, and combativeness following loss of 24h home aide.

Plan:

• Dementia w/ Behavioral Disturbance

  • Geriatrics consulted for medication management

  • Continue home Seroquel 25 mg qhs

  • Continue home risperidone 0.25 mg at 7 am and 0.5 mg at 3 pm

  • Continue Lexapro (in place of home Celexa)

  • Geriatrics recommendations for agitation:

    1. Atarax 25 mg TID PRN anxiety

    2. Seroquel 25–50 mg TID PRN

    3. Risperdal 0.25 mg ODT BID PRN if unable to swallow/psychosis

    4. Zyprexa 2.5 mg IV/IM for acute safety threat (may repeat in 30 min if ineffective)

• # Hypothyroidism

  • TSH elevated with low FT4; patient nonadherent at home

  • Continue Synthroid 112 mcg daily

  • Repeat TSH in 4–6 weeks

• Hypertension

  • Continue losartan 100 mg daily (replacing home olmesartan 40 mg)

• Recurrent UTIs / Asymptomatic Bacteriuria

  • Hold antibiotics per ID (likely colonization)

  • Consider methenamine + vitamin C to acidify urine

• Hypercalcemia (chronic)

  • iCal 5.50, PTH mildly elevated (possible primary hyperparathyroidism)

  • Monitor

Comorbidities on Admission:

• Chronic HFrEF (EF 29%, 12/30/24)

• Thrombocytopenia

• Chronic anemia

• PMH of COVID

Secondary Diagnoses: Hypercalcemia, Thrombocytopenia

Diet: Regular with nutritional supplements
VTE PPx: Enoxaparin 40 mg SC daily
Medication Reconciliation: Partially complete
Communication: RN and Case Management

Discharge Readiness:

• Expected Discharge Date: 10/13/25

• AM-PAC (RN/PT): 15 / —

• Expected Disposition: Undetermined

• Barrier(s): Behavioral improvement and safe dispo plan

• Code Status: Full Code

Patient 3:
54 y.o. female recently released from jail with history of polysubstance use (OUD, cocaine), PTSD, who presented with fever and back pain after IVDU; found to have Serratia marcescens bacteremia.

Findings:
MRI spine → discitis/OM L4–S1 with ventral epidural and psoas phlegmon; severe spinal stenosis. No drainable collection.

Plan:

• # Serratia marcescens bacteremia / Discitis / Epidural Phlegmon

  • Continue ceftriaxone x6 weeks (EOT ~11/6/25)

  • ID & neurosurgery following

  • PICC deferred d/t recurrent fevers

  • Continue pain management (oxycodone, lidocaine patch, Tylenol, PRN Flexeril/Motrin, gabapentin)

  • Workup for noninfectious fever ongoing (CT A/P, TTE, cortisol, D-dimer all non-revealing)

• # Polysubstance Use Disorder / IVDU

  • Utox + for fentanyl, cannabinoids

  • Started on suboxone; addiction medicine following for placement

Diet: Regular
Medication Reconciliation: Partially complete
Communication: RN, ID, Addiction Medicine

Patient 4:
73 y.o. female with dementia (nonverbal baseline), seizures, SDH (burr hole), OSA (CPAP), Afib (not on AC), and HTN, admitted with weakness and lethargy → septic shock (UTI vs CAP) → required pressors and intubation (extubated 9/26).

Plan:

• # CAP vs UTI (resolved)

  • Completed Zosyn x7d

  • Hemodynamically stable; pancytopenia resolved

• # Dysphagia, Severe Malnutrition

  • NG feeds continued; encourage PO intake as tolerated

  • Family declined G-tube; FULL CODE; CPAP even during naps to reduce hypercarbia

  • Maintain NG feeds; encourage oral feeding when alert

• # Encephalopathy

  • At baseline severe dementia; intermittently follows commands, nonverbal

• Chronic Issues:

  • OSA on CPAP nightly and during naps

  • Seizure disorder – continue Keppra

  • Afib – on ASA only

  • HTN – continue losartan

Dispo: Pending improved oral nutrition; may need renewed GOC if no progress
Code Status: Full Code

Patient 5:
61 y.o. male with Afib (on Eliquis), CVA/TIA, T2DM, AUD, s/p R BKA, and MDD, who presented after suicide attempt via gabapentin overdose (now cleared by psych). Course notable for intractable hiccups (resolved) and bowel/bladder incontinence (improved). Now medically stable; awaiting conservatorship/T19 for safe dispo.

Plan:

• # FTT / Mild Cognitive Impairment / MDD (hx SI)

  • Continue Cymbalta 20 mg daily

  • Cleared by psych; lacks capacity → cannot leave AMA

  • Undergoing conservatorship/T19 for STR vs LTC

  • Referral to Adler Center at discharge

• # Lower Back Pain (MSK)

  • Continue multimodal pain regimen (APAP, Flexeril PRN, lidocaine patch, heat)

  • Avoid NSAIDs while on anticoagulants

• # Splenic Infarct (incidental)

  • Continue Eliquis + Plavix

  • Heme signed off

• # DM2

  • A1c 7.0 (9/25/25)

  • Continue linagliptin 5 mg daily; ISS low dose

  • Monitor diet adherence; adjust if glucose >180

• # Chronic Conditions

  • RLS – continue ropinirole 4 mg qhs

  • HTN/Afib/CVA – continue Eliquis, Plavix, metoprolol 25 mg, amlodipine 10 mg, statin

  • Chronic LBP – continue buprenorphine and acetaminophen

Comorbidities on Admission: Transportation insecurity
Secondary Diagnoses: Hypokalemia, Hypomagnesemia, Hyponatremia, DM with hyperglycemia

Diet: Regular
VTE PPx: Apixaban 5 mg
Medication Reconciliation: Partially complete
Communication: RN and Case Management

Discharge Readiness:

• Expected Discharge Date: 10/24/25

• AM-PAC (RN/PT): 14 / 12

• PT Dispo: Moderate complexity (10/9/2)

• Expected Location: TBD (awaiting conservatorship)

• Code Status: Full Code