Field Notes November 13th

SBAR #74

Situation:
30-year-old male with schizoaffective disorder, history of paranoid delusions and violent threats, recently released from incarceration, presented from APT Foundation with altered mental status (AMS), tremors, tachycardia, and hypertension.

Background:
CT head and EEG negative; ammonia mildly elevated, ethanol level 11; TSH normal; CK mildly elevated. Suspected acute psychosis likely due to medication noncompliance during transition from correctional to psychiatric care.

Assessment:

• A&Ox4

• Room air

• AMS with tremors and hypertension likely secondary to abrupt Depakote cessation.

• Psychosis stable on Olanzapine 5 mg BID with sitter for violent ideation.

• Low urine output (urinary retention); mild leukocytosis without infection source.

• Hypertension stable on Lisinopril; switching Clonidine to Propranolol for tremor and BP control.

• Chest pain resolved; ECG/troponin negative.

Recommendation:

1. Continue 1:1 sitter for safety.

2. Continue Olanzapine 5 mg BID; monitor urinary retention.

3. Continue Propranolol 10 mg TID (for tremor, tachycardia).

4. Continue IV fluids and bladder scans q6h; straight cath PRN.

5. Trend LFTs and CBC.

6. Continue Lisinopril for HTN.

7. Coordinate with psych for med reconciliation with Garner Facility.

Rationale for interventions:

• 1:1 sitter: Prevents self-harm or violence during acute psychosis.

• Olanzapine: Antipsychotic for mood stabilization and psychosis control.

• Monitor urinary retention: Anticholinergic side effect of Olanzapine.

• Propranolol: Nonselective β-blocker reduces tremors and sympathetic overactivity.

• IV fluids & bladder scans: Support renal perfusion, treat retention, prevent AKI.

• Trend LFTs/CBC: Detect medication-induced hepatic or hematologic effects.

• Psych coordination: Ensures accurate continuation of prior regimen, reducing relapse risk.

SBAR #73

Situation:
71-year-old male with CAD (s/p LAD PCI 2017), HTN, HLD, MDD, and vascular dementia presented with worsening confusion; self-called 911.

Background:
Lives alone after sister moved out. Son reports progressive paranoia and hallucinations. CT head negative; chest x-ray with possible opacity; platelets low (73); alkaline phosphatase elevated; otherwise stable.

Assessment:
Likely progression of vascular dementia. No infection, electrolytes normal, afebrile, and hemodynamically stable. Mild chronic liver enzyme elevation and new thrombocytopenia.

Recommendation:

1. Admit to medicine for observation.

2. Continue trazodone 25 mg HS for agitation/sleep.

3. Continue cardiac meds (ASA, metoprolol, Imdur).

4. Continue Lexapro 10 mg daily for depression.

5. Check GGT to assess liver source of ALP elevation.

6. Monitor CBC for thrombocytopenia trend.

7. Cardiac diet and fall precautions.

8. Confirm home meds with son.

Rationale for interventions:

• Admission: Allows monitoring of mental and medical status in safe environment.

• Trazodone: Sedating antidepressant used for sleep and agitation in dementia.

• Cardiac meds: Prevent angina or MI recurrence.

• Lexapro: Maintains mood stability; depression can worsen cognition.

• GGT test: Distinguishes liver vs. bone etiology of elevated ALP.

• CBC monitoring: Detects progression of thrombocytopenia or bleeding risk.

• Cardiac diet: Controls hypertension and CAD progression.

• Home med verification: Ensures accuracy and prevents drug duplication or omission.

SBAR #64

Situation:
69-year-old male with asthma, COPD, CAD s/p PCI, HFpEF, alcohol use disorder, and HTN admitted for acute hypoxemic respiratory failure and alcohol withdrawal.

Background:
Drinks 1 pint of vodka daily. On Valium taper for withdrawal. Weaned off oxygen.

Assessment:
Improving respiratory status, stable vitals, mild hypertension. No active withdrawal symptoms.

Recommendation:

1. Continue prednisone 40 mg daily ×5 days.

2. Continue Symbicort and Spiriva inhalers.

3. Continue Valium taper for alcohol withdrawal.

4. Follow up on echocardiogram results.

Rationale for interventions:

• Prednisone: Reduces airway inflammation in COPD exacerbation.

• Symbicort (ICS/LABA): Improves airflow and reduces exacerbation frequency.

• Spiriva (LAMA): Maintains bronchodilation and decreases mucus hypersecretion.

• Valium taper: Prevents seizures and autonomic instability during alcohol withdrawal.

• Echocardiogram: Evaluates cardiac function in setting of HFpEF and prior CAD.

SBAR #65

Situation:
54-year-old female with autoimmune disease (SLE vs. dermatomyositis), Type II DM, Crohn’s disease, bipolar disorder, chronic abdominal pain, and malnutrition—now s/p G-J tube (11/6/25).

Background:
Transferred from inpatient psychiatry for persistent vomiting, weight loss, and abdominal pain. Pain worsened after buprenorphine initiation. Refusing gabapentin/pregabalin. Evaluated by GI, psychiatry, and pain management.

Assessment:
Chronic pain likely multifactorial—functional GI component, visceral hypersensitivity, and opioid-induced hyperalgesia. Malnutrition improving on tube feeds. Mood unstable due to uncontrolled pain.

Recommendation:

1. Continue G-J tube feeds at goal rate per RD.

2. Continue Oxycodone 10 mg q4h PRN (short-term).

3. Continue Buprenorphine 8 mg TID (plan outpatient taper).

4. Continue Robaxin 1000 mg TID, lidocaine patches, capsaicin cream.

5. Continue bowel regimen: Senna, Miralax.

6. Monitor EKG for QTc prolongation on Seroquel/Fluoxetine.

7. Continue Seroquel 175 mg HS + 25 mg AM.

8. Continue Fluoxetine 40 mg daily.

9. Continue levothyroxine for hypothyroidism; recheck TSH in 6–8 weeks.

10. Continue Losartan/Toprol XL for HTN, Lispro for DM.

11. Palliative and psychiatry follow-up before discharge.

Rationale for interventions:

• Tube feeding: Provides nutritional support, prevents further catabolism.

• Oxycodone short-term: Controls breakthrough pain while preventing withdrawal.

• Buprenorphine taper plan: Minimizes dependence while treating baseline pain.

• Robaxin/lidocaine/capsaicin: Multimodal pain control reduces opioid use.

• Bowel regimen: Prevents opioid-induced constipation.

• EKG monitoring: Prevents arrhythmias from QT-prolonging meds.

• Psych meds: Stabilize mood and prevent suicidal ideation.

• Levothyroxine: Corrects hypothyroidism and supports metabolic recovery.

• Antihypertensives/insulin: Maintain BP and glycemic control during recovery.

• Palliative/psych follow-up: Coordinates symptom and mental health management.