Field Notes On November 1st

CASE 1

81 y.o. male with PMHx T2DM, vestibular neuritis, BPPV, chronic back pain, MASH, essential tremor, s/p cholecystectomy, pancreatic insufficiency, presented after a fall; found COVID positive.

Situation

• Presented after a fall with possible syncope

• No acute pain, chest discomfort, or respiratory distress.

• Telemetry monitoring ongoing.

Background

• Hx of orthostatic hypotension and polypharmacy.

• Benzo use disorder

• PMHx includes multiple comorbidities contributing to fall risk and autonomic instability.

Assessment

• Neuro: A&O x3; interpreter used for Mandarin.

• Resp: RA, unlabored.

• CV: Stable, denies SOB/CP.

• GI/GU: CC diet tolerated, continent, LBM 10/30.

• MSK/Skin: Ambulates SBA w/RW; skin CDI.

• Pain: Denies pain.

• Access: L PIV, CDI.

• Active issues: Orthostatic hypotension, mild COVID-19 infection, chronic anemia, parkinsonism, hearing loss.

Recommendations / Interventions with Rationales

• Fall precautions – reduce risk of repeat injury given orthostasis and polypharmacy.

• Telemetry monitoring – assess for arrhythmias as potential cause of syncope.

• Compression stockings + abdominal binder – improve venous return and mitigate orthostatic hypotension.

• Encourage oral fluids – maintain euvolemia and prevent dehydration-induced hypotension.

• Medication review – reduce agents worsening orthostasis (clonidine, SGLT-2 inhibitors).

• PT/OT + swallow eval – address fall and aspiration risk.

• COVID monitoring – daily O₂ sat, vitals, I/O for early detection of progression.

• Anemia workup (B12/iron) – evaluate chronic etiology and prevent fatigue contributing to falls.

• Hearing assessment – outpatient ENT/audiology to improve communication and orientation.

• PPx: SQH/Lovenox – DVT prophylaxis.

• Diet: Consistent Carb – optimize glycemic control in T2DM.

Note:
Patient stable on RA. Continue monitoring orthostatic BP. Encourage mobility with supervision. Discharge planning to include life alert and medication reconciliation to reduce polypharmacy.

CASE 2

66 y.o. female with PMHx HTN, asthma, AF (on Eliquis), schizophrenia, presented for N/V/D, now resolved.

Situation

• Admitted for 2 weeks of N/V/D, now resolved.

• Maintaining oral intake, VSS, afebrile.

Background

• PMHx: AF, HTN, hyperthyroidism, schizophrenia, asthma.

• On anticoagulation and beta-blocker.

Assessment

• AOx4, VSS on RA, diminished lung sounds, HR 90–100 (Afib).

• Rash to breasts treated with clotrimazole.

• Bedrest, obese, assist x2, external cath in place.

• Refused AM labs.

Recommendations / Interventions with Rationales

• Monitor for recurrent GI symptoms – ensure stability before discharge.

• F/U stool, blood, urine cultures – confirm infection resolution.

• IV fluids PRN – maintain hydration and electrolyte balance (rationale: prevent AKI from dehydration).

• Continue metoprolol, Eliquis – rate control and stroke prevention in AF.

• Continue methimazole – maintain euthyroid state.

• Apply clotrimazole cream – treat intertrigo fungal rash; stop nystatin powder (less effective).

• Continue Seroquel, melatonin – stabilize psychiatric status and promote sleep.

• Echo/EKG – monitor cardiac function given AF.

• Encourage mobility – prevent DVT, improve bowel motility.

Notes:

Monitor fluid status and electrolytes. Reinforce skin care and hygiene for intertrigo. Reassess willingness for lab draws. Continue cardiac and psychiatric medication adherence.

CASE 3

89 y.o. female with pAF/flutter on amio/eliquis, CAD, HFpEF, O2-dependent COPD, chronic hypercarbic respiratory failure, schizoaffective d/o. Recently readmitted for COPD exacerbation and pneumonia.

Situation

• Readmitted 10/27 with acute on chronic hypercarbic respiratory failure and pneumonia.

• Currently stable on 2L NC, using BiPAP at night.

Background

• Multiple chronic conditions including COPD, HFpEF, and CAD.

• On amiodarone, Eliquis, metoprolol, spiriva, budesonide, olanzapine.

• CXR: bilateral lower lobe opacities (RLL new/worsened).

Assessment

• SpO₂ 95% on 2L NC, mild expiratory rhonchi.

• ABG improved (7.37).

• Afebrile, hemodynamically stable.

• Foley removed; spontaneous voiding.

• CXR improved; cultures negative.

Recommendations / Interventions with Rationales

• Continue nightly BiPAP – correct hypercarbia and prevent CO₂ narcosis.

• Maintain O₂ 2–4L, titrate per SpO₂ > 90% – prevent hypoxemia.

• Budesonide, Spiriva, Duonebs – reduce airway inflammation, promote bronchodilation.

• Complete 7-day abx course (PO cefuroxime + doxycycline) – resolve pneumonia and prevent relapse.

• Monitor ABGs and mental status – early detection of CO₂ retention.

• Tamsulosin 0.4mg daily – prevent urinary retention and maintain bladder emptying.

• PT/OT moderate complexity – optimize function prior to SNF return.

• HOLD losartan, metformin – avoid hypotension and lactic acidosis with AKI risk.

• Continue insulin regimen – manage DM safely.

• Olanzapine 7.5mg nightly – stabilize mood and reduce psychotic features.

• Monitor calcium carbonate, protonix, miralax – maintain GI function and prevent constipation.

• Continue Eliquis – prevent thromboembolic complications.

Notes:
Respiratory status improved; continue pulmonary hygiene and mobility. Reassess for discharge back to SNF when stable. Monitor for delirium due to hypercarbia.

CASE 4

70 y.o. female with Parkinson’s Disease, Lewy Body Dementia, hypothyroidism, GERD, arthritis, admitted for AMS and weakness with delirium.

Situation

• Admitted with AMS and increased urinary frequency, likely multifactorial delirium.

• Continues to refuse Sinemet, contributing to worsening parkinsonism and confusion.

Background

• PMHx Parkinson’s disease, LBD, hypothyroidism, GERD, arthritis, B12 deficiency.

• Recently treated empirically for UTI, culture grew mixed flora.

Assessment

• AOx1–2, disoriented to time/place/situation.

• VSS on RA, diminished lung sounds.

• NPO except meds, bedrest assist x2.

• LBM 10/30.

• Family supportive, aware of potential NG tube if oral intake declines.

Recommendations / Interventions with key Rationales

• Delirium precautions (quiet environment, orientation cues, minimize nighttime disturbances) – reduce sensory overload and confusion.

• Encourage Sinemet adherence – optimize dopamine levels, reduce rigidity and cognitive decline.

• Monitor calcium levels – rule out metabolic cause of confusion.

• Encourage PO intake or IV fluids PRN – prevent dehydration-related delirium.

• Pain management + heating pads – relieve neck pain and promote comfort.

• Outpatient follow-up for parotid tail mass – monitor for neoplastic process.

• Continue rivastigmine patch – support cognitive function.

• Continue levothyroxine, pepcid – manage chronic conditions to prevent metabolic decompensation.

• PT/OT + family education – reduce immobility and improve participation in care.

• Delirium documentation and family involvement – prevent unnecessary restraints and promote calm reorientation.

Notes:
Delirium likely related to medication refusal. Continue supportive care and hydration. If persistent nonadherence, reassess for NG tube placement. Monitor for aspiration risk and maintain fall precautions.

Case 5

Situation:
70-year-old woman with extensive medical history including hypertension, type 2 diabetes mellitus (with neuropathy and gastroparesis), essential thrombocythemia, severe peripheral arterial disease s/p left below-knee amputation, CKD stage 5 (not on dialysis), and history of GI bleeding.
She presents with acute epigastric pain, nausea, vomiting, and dark stools over several days.

Background:

• Prior endoscopic evaluations this year:

  • EGD (2025) – unremarkable

  • Push enteroscopy (2025) – erosive gastropathy

  • Colonoscopy (2025) – diverticulosis, hemorrhoids, tubular adenomas removed

• Imaging:

  • CT Abdomen – distal esophageal wall thickening vs hiatal hernia

  • Ultrasound GB – gallbladder distention with wall edema and sludge, no acute cholecystitis

  • Lipase elevated (200 U/L) but no radiologic evidence of acute pancreatitis

• Labs:

  • WBC 26.3 ↑ (leukocytosis)

  • Platelets >900K (essential thrombocythemia)

  • Creatinine 8.2 (CKD G5)

  • H/H stable (13.0/42.0)

Assessment:
Upper abdominal pain and dark stools in the setting of erosive gastropathy and CKD, but no active GI bleed or evidence of pancreatitis or cholecystitis. Findings likely multifactorial, possible gastroparesis exacerbation, hiatal hernia/esophagitis, or slow gastric motility secondary to diabetes.

Recommendation:

• Continue PPI therapy (Pantoprazole 40 mg IV Q12H) to reduce gastric acid secretion and protect mucosa.

• Monitor for GI bleeding (check stools, serial H/H, vitals).

• Hold anticoagulants and antiplatelets (Apixaban, Clopidogrel) until GI bleed is ruled out.

• Gastric emptying study to evaluate for delayed gastric motility related to diabetic gastroparesis.

• Continue Reglan (Metoclopramide) to promote gastric emptying and relieve nausea.

• Maintain hydration while monitoring renal function closely (CKD G5).

• Reassess if symptoms worsen, consider HIDA scan or repeat endoscopy if bleeding recurs.

Rationales for Interventions

Intervention	Rationale
Continue IV PPI (Pantoprazole 40 mg Q12H)	Reduces gastric acid secretion and promotes healing of erosive mucosa; prophylaxis against upper GI bleed.
Hold Apixaban and Clopidogrel	Prevents potential worsening of bleeding in the setting of dark stools and GI history.
Monitor for bleeding (stool color, H/H, vitals)	Detects early evidence of recurrent or occult GI bleeding.
Gastric emptying study	Confirms gastroparesis as a cause of persistent nausea, vomiting, and early satiety in diabetic patients.
Continue Metoclopramide (Reglan)	Enhances gastric motility and reduces symptoms of nausea/vomiting associated with gastroparesis.
Monitor renal function and fluid status	CKD G5 predisposes to fluid overload and metabolic derangements; careful balance of hydration is needed.
Continue antibiotics (Zosyn, Vancomycin)	Addresses possible infection source contributing to leukocytosis until culture results clarify etiology.

Date/Time: 11/01

Subjective:
Patient reports persistent upper abdominal pain with nausea and intermittent dark stools. Denies hematemesis or coffee-ground emesis.

Objective:
Afebrile, BP 180/65, HR 94. Abdomen soft, nondistended, nontender. H/H stable. WBC and platelets elevated; creatinine 8.2. Imaging shows gallbladder wall edema without cholecystitis, and distal esophageal thickening vs hiatal hernia.

Assessment:
69F with complex medical history presenting with upper abdominal discomfort, nausea/vomiting, and dark stools likely due to gastroparesis exacerbation or erosive gastropathy, not acute GI bleed or pancreatitis.

Plan:

• Continue IV PPI

• Hold Apixaban/Clopidogrel

• Continue Reglan for gastric motility

• Gastric emptying study

• Monitor for GI bleeding and renal function

• Continue Zosyn/Vancomycin pending cultures

• Reassess need for HIDA or endoscopy if symptoms persistent.