Field Note

CASE 1

Situation:

86-year-old female with history of HTN, HLD, NICM (EF 21%), HFrEF, breast cancer s/p chemo/RT, and asthma, admitted for acute hypoxemic respiratory failure secondary to COVID-19. Now off O₂ but with poor appetite, AKI resolved, and ongoing cognitive decline.

Background:
Initially treated with dexamethasone and remdesivir for COVID-19. Mild volume overload resolved; diuretics paused due to AKI. Poor oral intake persists; plan to restart mirtazapine for appetite and mood.

Assessment:

• COVID-19 improving; respiratory status stable on room air

• Euvolemic, AKI resolved, mild transaminitis improving

• Persistent poor intake, malnutrition, cognitive impairment, and possible delirium

• Weakness requiring STR on discharge

R – Recommendation:

• Continue supportive care and incentive spirometry

• Resume mirtazapine 7.5 mg QHS, increase to 15 mg if tolerated

• Continue PT/OT for strength and mobility

• Monitor I&O, daily weights, CMP, and LFTs

• Hold losartan until renal function and BP stabilize

• Consider metoprolol 12.5 mg daily if BP remains stable

• Encourage nutrition and hydration; family education on intake

• Arrange geriatrics follow-up for cognitive evaluation

Rationales:

• Mirtazapine improves appetite and mood (addresses poor intake/malnutrition).

• Holding losartan prevents further renal compromise post-AKI.

• Physical therapy mitigates deconditioning and discharge risk.

• LFT and CMP monitoring detects drug-induced or COVID-related hepatic injury.

• Metoprolol cautiously added once hemodynamically stable to support HF management.

• Family involvement reinforces feeding and medication adherence post-discharge.

CASE 2
Situation:
89-year-old male with dementia, dysphagia, BPH, and spinal stenosis admitted from SNF after choking and developing cough and respiratory distress.

Background:
Diagnosed with aspiration pneumonitis from gastric secretions; currently on Unasyn, NPO, and receiving oxygen and nebulizers.

Assessment:

• Aspiration pneumonia with respiratory distress

• Dysphagia requiring evaluation

• Alzheimer’s dementia contributing to aspiration risk

• Stable on oxygen and antibiotics

Recommendation:

• Continue IV Unasyn for aspiration pneumonia

• Maintain NPO until swallow evaluation completed

• Provide IV fluids for hydration

• Continue O₂ support and nebulizer treatments PRN

• Repeat CBC and monitor WBC and temperature

• Implement aspiration precautions

• Initiate DVT prophylaxis with LMWH

Rationales:

• Unasyn provides coverage for anaerobes in aspiration pneumonia.

• NPO status prevents further aspiration until cleared by speech therapy.

• IV fluids maintain hydration while oral intake is restricted.

• Nebulizers and O₂ reduce bronchospasm and hypoxemia.

• CBC trending tracks infection resolution.

• Aspiration precautions prevent recurrence in dementia patients.

• LMWH prevents DVT in immobile, elderly patients.

CASE 3
Situation:
65-year-old male with gastroparesis, type 1 diabetes, depression, HTN, and recurrent admissions for abdominal pain and vomiting admitted for acute flare of gastroparesis.

Background:
Presented with epigastric pain, low suspicion for pancreatitis; cannabis use noted. Diabetic management adjusted due to poor intake.

Assessment:

• Gastroparesis flare with nausea, vomiting, and poor PO tolerance

• T1DM with hypoglycemia risk due to decreased intake

• History of cannabis use contributing to GI symptoms

• Stable vitals, improving with supportive care

Recommendation:

• Continue antiemetics (compazine, zofran) and nortriptyline

• Advance diet as tolerated

• Switch from IV to PO pain management; hold IV opioids

• Adjust insulin to prevent hypoglycemia

• Continue antihypertensives, statin, and psychiatric medications

• Encourage abstinence from cannabis

Rationales:

• Antiemetics and nortriptyline improve gastric emptying and nausea control.

• Gradual diet advancement reduces symptom recurrence.

• Avoiding IV opioids prevents gastroparesis worsening.

• Insulin adjustment aligns with reduced intake to prevent hypoglycemia.

• Psychiatric medication continuation supports mental stability.

• Cannabis cessation essential for reducing hyperemesis recurrence.

CASE 4
Situation:
54-year-old female with BPAD, depression, DMII, Crohn’s disease, and chronic abdominal pain admitted for persistent pain, weight loss, and need for nutritional support.

Background:
GI and IR consulted; GJ tube placed for nutrition; NPO for 24 hours post-procedure. Receiving LR and planned tube feeds.

Assessment:

• Malnutrition secondary to poor oral intake

• GJ tube successfully placed

• At risk for refeeding syndrome and electrolyte disturbances

• Stable mood; psychiatry following

Recommendation:

• Maintain NPO for 24 hours post-procedure, then start TF (Glucerna 1.2 at 60 ml/hr)

• Continue LR 75 cc/hr until TF started

• Monitor BMP, Mg, Phos, and Ca q12h for refeeding risk

• Continue PPI for esophagitis

• Provide scheduled and PRN pain control (acetaminophen, buprenorphine, oxycodone, Dilaudid)

• Continue psychiatric medications and monitor affect

• Continue Synthroid and Crestor

• Monitor blood glucose; SSI as needed

Rationales:

• Post-procedure NPO prevents aspiration and leakage at the GJ site.

• TF initiation and monitoring ensure gradual nutritional repletion.

• Q12H labs prevent severe electrolyte shifts (refeeding).

• Pain regimen provides multimodal control while avoiding GI irritation.

• Psychiatric med continuity maintains emotional stability.

• Synthroid and Crestor address chronic conditions safely during recovery.