Field Note December 6th

70M

Situation:
79-year-old male admitted for aggressive behavior requiring restraints.

Background:
PMHx: Alzheimer’s dementia, alcohol use disorder, HTN, hepatitis C with cirrhosis, tobacco use disorder.

Assessment:
AOx2, RA, soma bed, skin intact, x1 assist, no IV access.

Recommendation:

• Olanzapine 5 mg BID
• PRN hydroxyzine 10 mg PO or olanzapine 2.5 mg IM Q6H
• Continue mirtazapine 7.5 mg nightly
• Stop trazodone
• Discontinue SOMA bed
• Lisinopril for HTN
• Nicotine lozenges PRN
• PT consult, delirium precautions

69F

Situation:
67-year-old female admitted for catatonia with plan for ECT. Bedbound, full code, foley catheter, PICC in right UA, regular diet (feeder).

Background:
PMHx: NPH s/p VP shunt, bipolar disorder, HTN, seizure disorder, progressive gait disorder, parkinsonism, tardive dyskinesia. Allergies: PCN, anesthesia. Chronic moderate hydronephrosis since 2022. Vaginal ring needs outpatient replacement. LFTs previously elevated (likely PCN-related).

Assessment:
AOx2, bedbound, soft BP, Foley in place, PICC intact.

Recommendation:

• Continue Ativan 1 mg TID
• Seroquel 25 mg QHS
• Vimpat for seizures
• Hold Igrezza today
• Psych consult for ECT
• Hold Norvasc & propranolol for soft BP
• Continue Flomax
• Continue Eliquis for PE
• Soft diet with thin liquids

81M

Situation:
84-year-old male admitted for hematochezia with Hb drop while on DOAC.

Background:
PMHx: Afib on rivaroxaban, recurrent syncope s/p pacemaker, HTN, HLD, GERD, glaucoma, thrombocytopenia, herpes zoster ophthalmicus, BPH.

Assessment:
AOx3, RA, on tele, SBA x1 OOB.

Recommendation:

• Hold rivaroxaban
• Continue metoprolol (with hold parameters)
• Resume Crestor, acyclovir, tamsulosin
• GI consult
• Type & screen, 2 large bore IV
• Monitor BP (received hydralazine 25 mg PO in ED)
• CLD diet

MOA for Medications

• Ativan (Lorazepam): Benzodiazepine; enhances GABA-A receptor activity → CNS depression, anxiolytic, anticonvulsant.
• Seroquel (Quetiapine): Atypical antipsychotic; antagonizes serotonin (5-HT2) and dopamine (D2) receptors → antipsychotic, sedative.
• Igrezza (Valbenazine): VMAT2 inhibitor; reduces dopamine release → treats tardive dyskinesia.
• Vimpat (Lacosamide): Enhances slow inactivation of voltage-gated sodium channels → stabilizes neuronal membranes.
• Norvasc (Amlodipine): Calcium channel blocker; inhibits calcium influx in vascular smooth muscle → vasodilation, ↓ BP.
• Propranolol: Non-selective beta-blocker; ↓ sympathetic activity → ↓ HR, BP, tremor.
• Flomax (Tamsulosin): Alpha-1 blocker; relaxes bladder neck and prostate → improves urine flow.
• Eliquis (Apixaban): Factor Xa inhibitor; prevents thrombin formation → anticoagulant.
• Olanzapine: Atypical antipsychotic; antagonizes dopamine and serotonin receptors → reduces agitation.
• Hydroxyzine: H1 receptor antagonist; sedative and anxiolytic effects.
• Mirtazapine: Alpha-2 antagonist; ↑ norepinephrine and serotonin release → antidepressant.
• Lisinopril: ACE inhibitor; ↓ angiotensin II → vasodilation, ↓ BP.
• Nicotine lozenges: Nicotinic receptor agonist; reduces withdrawal symptoms.
• Metoprolol: Beta-1 selective blocker; ↓ HR and BP → rate control in Afib.
• Crestor (Rosuvastatin): HMG-CoA reductase inhibitor; ↓ cholesterol synthesis.
• Hydralazine: Direct arteriolar vasodilator; ↓ systemic vascular resistance → ↓ BP.
• Acyclovir: Inhibits viral DNA polymerase → prevents viral replication.
• PPI (Pantoprazole): Irreversible H+/K+ ATPase inhibitor → ↓ gastric acid secretion.

Quick Pathophysiology for Conditions

• Catatonia: Severe psychomotor disturbance linked to GABA and dopamine dysfunction; often associated with psychiatric disorders.
• Parkinsonism: Loss of dopaminergic neurons in substantia nigra → motor rigidity, tremor.
• Seizure disorder: Abnormal neuronal firing due to imbalance of excitatory/inhibitory neurotransmitters.
• Alzheimer’s dementia: Beta-amyloid plaques and tau tangles → neuronal death, cognitive decline.
• Cirrhosis: Chronic liver injury → fibrosis, portal hypertension, impaired detoxification.
• Hematochezia: Lower GI bleeding; causes include diverticulosis, angiodysplasia, anticoagulation.
• Afib: Disorganized atrial electrical activity → irregular ventricular response, risk of thromboembolism.
• Thrombocytopenia: Low platelet count → impaired clotting, bleeding risk.
• Herpes Zoster Ophthalmicus: Reactivation of VZV in ophthalmic branch → ocular inflammation.
• BPH: Hyperplasia of prostate → urinary obstruction.

Notes:

AOx2, bedbound, foley in place, PICC intact, soft BP, feeder, regular diet.
AOx2, RA, soma bed, skin intact, x1 assist, no IV access.
AOx3, RA, on tele, SBA x1 OOB, CLD diet.

Public Service A:

Thank Goodness it's Saturday. As always, I will be available via my office phone 411-246-1683 and secure chat from 7:00 AM to 7:00 PM should any clinician/case manager need to reach me. They know where to find me.

RRT TO AME

Hematochezia: Blood-tinged feces

Hypertensive urgency: Hypertensive urgency
Longstanding persistent atrial fibrillation (HC Code): Longstanding persistent atrial fibrillation

Past Medical History

• Arthritis 
• BPH (benign prostatic hyperplasia)
• Cataracts, bilateral
• Disease of thyroid gland – nodules
• Falls
• Fracture –(nasal)
• GERD (gastroesophageal reflux disease)
• Glaucoma
• H/O reduction of nasal fracture
• Headache
• History of thyroid nodule
• Hx laparoscopic cholecystectomy
• Hydronephrosis 
• Hyperlipemia
• Hypertension
• Impaired memory
• Impairment of balance
• Intraventricular cyst of brain
Surgery on for management of a suprasellar/third ventricular cystic lesion resulting in obstructive hydrocephalus of the left lateral ventricle
• Obstructive hydrocephalus 
• S/P cystourethroscopy with dilation of urethral stricture
• S/P TURP (status post transurethral resection of prostate)
• Syncope
• Syncope, psychogenic
• Syncope, unspecified syncope type
• Urinary tract infection due to Klebsiella species
• Wears glasses

Intubation – Bedside

Date/Time: 12/6/2025 10:11 AM
Performed by: X
Authorized by: X

Time Out:

• Documented by nurse: No
• Unable to perform due to emergent nature: Yes
• Initiated prior to procedure: Yes
• Patient ID and procedure confirmed: Yes
• Consent verified: Yes
• Site marked per policy: Yes
• Imaging or laterality band present: Yes

Patient location: Floor
Provider intubating: Attending

Indications:

• Type of tube: Endotracheal tube (ETT)
• Location: Oral
• Type of intubation: Rapid sequence induction
• Indication: Airway protection and altered consciousness

Pre-procedure details:

• Mallampati score: Not assessed
• Preoxygenation: Bag-valve mask
• Oral aperture: Not assessed
• Thyromental distance: Not assessed
• Neck range of motion: Not assessed
• C-Collar: No

Procedure details:

• Induction: Propofol (40 mg)
• Paralytic: Succinylcholine (80 mg)
• CPR in progress: No
• Attempts: 1
• Method: Video laryngoscopy
• Blade: DL Mac (curved), size 4
• Cricoid pressure: No
• Tube visualized through cords: Yes
• Cormack-Lehane view: Grade 2a
• Tube size: 7.5 mm, cuffed
• Difficult airway: No

Placement assessment:

• ETT at lip: 22 cm
• Breath sounds: Equal
• Verification: Equal breath sounds and capnography waveform
• End-tidal CO₂: Yes

Post-procedure:

•  purposes?

Cardizem (diltiazem) – Mechanism of Action (MOA)

Cardizem is a calcium channel blocker (CCB), specifically a non-dihydropyridine type. Its MOA involves:

1. Blocks L-type calcium channels in:
• Cardiac muscle (myocardium)
• Vascular smooth muscle
2. Effects on the heart:
• ↓ Calcium influx during depolarization → ↓ contractility (negative inotropy)
• ↓ SA node automaticity → ↓ heart rate (negative chronotropy)
• ↓ AV node conduction → slows ventricular response (negative dromotropy)
3. Effects on blood vessels:
• Relaxation of vascular smooth muscle → vasodilation
• ↓ Systemic vascular resistance → lower blood pressure

Clinical Uses

• Hypertension
• Angina (especially variant/Prinzmetal)
• Rate control in atrial fibrillation/flutter and supraventricular tachycardia

Key Outcomes

• ↓ Myocardial oxygen demand
• ↓ Afterload
• ↓ Heart rate and AV conduction

Case X

Situation:
77 y/o male with Afib on Eliquis, HFpEF, chronic DVT (IVC filter), BLE paraplegia, chronic stage IV pressure ulcers with chronic OM, recurrent UTIs. Admitted 12/x for hypotension; course complicated by agitation and heavy sedation (resolved). Currently managing neurogenic hypotension, presumed UTI, urinary retention, anemia, and wound care.

Background:

• Afib on Eliquis
• HFpEF (last echo 2024)
• Chronic DVT, IVC filter
• BLE paraplegia (SCI 2008), wheelchair-bound
• Chronic sacral and ischial ulcers
• Multiple UTIs
• Labile BP, mild AKI resolved
• Mild hypothermia resolved
• AMS resolved after Zyprexa clearance

Assessment:

• Neurogenic hypotension: Labile BP, no organ hypoperfusion; non-pharmacologic measures initiated.
• Afib/HFpEF: Metoprolol titrated down due to hypotension; plan to switch to succinate 25 mg daily. Continue Eliquis.
• Anemia: Mixed iron deficiency/chronic disease; IV iron started, transfuse if Hgb <7.
• UTI: UA positive for Aerococcus; on CTX, will switch to amoxicillin at discharge.
• Urinary retention: Foley placed 12/4; persistent retention; discharge with Foley and urology follow-up.
• Constipation: On bowel regimen (miralax BID, senna BID).
• Sacral wound: High infection risk; wound care per protocol.
• BLE paraplegia: Continue baclofen.
• Nutrition: Regular diet + supplements.
• Code: Full Code.

Recommendation:

• Continue BP support (compression stockings, HOB 45°).
• Maintain antibiotic plan; monitor for infection signs.
• Continue IV iron; monitor Hgb.
• Foley care; educate patient/family on catheter maintenance.
• Strict wound care and repositioning Q2 hrs.
• Monitor mental status and hemodynamics.
• Discharge planning: Foley in place, outpatient urology, wound care follow-up.

Rationales:

• Metoprolol titration: Prevent hypotension while maintaining rate control.
• Compression stockings/HOB elevation: Improve venous return without fluid overload risk.
• Iron therapy: Correct anemia to improve oxygen delivery.
• Antibiotics: Treat Aerococcus UTI to prevent sepsis.
• Foley catheter: Prevent bladder overdistension and renal complications.
• Wound care/offloading: Reduce infection risk and promote healing.

Quick Note:

Patient A&O×3, wheelchair-bound. BP labile; HOB at 45°, compression stockings applied. On IV iron and CTX; plan to switch to oral antibiotics at discharge. Foley patent; urine output monitored. Wound care performed per protocol; sacral and ischial ulcers packed with NS-moistened kerlix, foam dressing applied. Turned Q2 hrs; heels offloaded; skin clean/dry. On bowel regimen; last BM 12/5. No acute distress noted.

Case  2:

Situation:
69 y/o male with DM, CAD, PAD, HTN, HLD, smoker, admitted for acute neuropsychiatric changes. MRI showed punctate infarcts; workup negative for reversible causes. Suspected frontotemporal dementia (primary progressive aphasia variant). Medically stable; pending conservatorship and Title 19.

Background:

• PMHx: DM, CAD s/p carotid stent, PAD s/p iliac stent, HTN, HLD, PVD, smoker.
• Presented with AMS, paranoia, bizarre behavior, suicidal ideation.
• MRI: multifocal infarcts; EEG, LP negative.
• Psychiatry: no SSRI due to agitation risk; on Depakote, trazodone PRN, olanzapine PRN.
• New Afib/Aflutter; EF 45% (HFmrEF).
• Moderate malnutrition; normocytic anemia; folate deficiency.

Assessment:

• Likely frontotemporal dementia: Non-reversible; outpatient neurocognitive clinic scheduled 1/27/26.
• Agitation: Managed with Depakote, trazodone PRN; elopement precautions in place.
• HFmrEF/Afib: GDMT as tolerated; on carvedilol, losartan, empagliflozin, spironolactone, aspirin, apixaban, statin.
• Hyponatremia: Improving; workup for SIADH ongoing.
• Anemia: Likely chronic disease; on folic acid and B12.
• Malnutrition: High-protein diet, supplements, calorie monitoring.
• T2DM: On metformin, Jardiance, sliding scale insulin.

Recommendation:

• Maintain safety: elopement precautions, avoid restraints unless necessary.
• Continue agitation management per psych recs; monitor LFTs and ammonia.
• Monitor electrolytes and cardiac status; maintain K>4, Mg>2.
• Continue nutrition plan; monitor intake and weight.
• Discharge planning: locked memory care facility once conservatorship finalized.

Rationales:

• Neurocognitive follow-up: Confirm dementia subtype for prognosis and care planning.
• Agitation precautions: Reduce risk of harm and maintain dignity.
• GDMT: Optimize cardiac function and reduce HF progression.
• Nutrition support: Prevent further decline and promote healing.
• Electrolyte monitoring: Prevent arrhythmias and complications.

Quick Note:

Patient intermittently agitated; elopement precautions in place. Out of bed in recliner when calm. On Depakote, trazodone PRN; olanzapine PRN available. Cardiac meds per GDMT; electrolytes monitored. Diet cardiac consistent carbs with supplements; calorie intake tracked. Foley not present; continent. Awaiting conservatorship for discharge planning. No acute distress noted.

Situation:
69 y/o male admitted for acute neuropsychiatric changes; suspected frontotemporal dementia (primary progressive aphasia variant). Medically stable, pending conservatorship and Title 19. Recent BP elevations noted.

Background:

• PMHx: DM, CAD s/p carotid stent, PAD s/p iliac stent, HTN, HLD, PVD, smoker.
• MRI: multifocal infarcts; workup negative for reversible causes.
• Psychiatry: on Depakote, trazodone PRN; olanzapine PRN available.
• New Afib/Aflutter; EF 45% (HFmrEF).
• Moderate malnutrition; normocytic anemia; folate deficiency.
• Hyponatremia improving; SIADH workup ongoing.
• Recent cognitive screen: MoCA 2/30.

Assessment:

• HTN: SBP 150–170s; goal <130 due to T2DM. Managed per HF GDMT (carvedilol, losartan, empagliflozin, spironolactone).
• Likely frontotemporal dementia: Non-reversible; outpatient neurocognitive clinic scheduled 1/27/26.
• Agitation: Managed with Depakote, trazodone PRN; elopement precautions in place.
• HFmrEF/Afib: GDMT as tolerated; on carvedilol, losartan, empagliflozin, spironolactone, aspirin, apixaban, statin.
• Hyponatremia: Improving; workup for SIADH ongoing.
• Anemia: Likely chronic disease; on folic acid and B12.
• Malnutrition: High-protein diet, supplements, calorie monitoring.
• T2DM: On metformin, Jardiance, sliding scale insulin.

Recommendation:

• Continue GDMT for HF and BP control; monitor SBP trends.
• Maintain safety: elopement precautions, avoid restraints unless necessary.
• Continue agitation management per psych recs; monitor LFTs and ammonia.
• Monitor electrolytes and cardiac status; maintain K>4, Mg>2.
• Continue nutrition plan; monitor intake and weight.
• Discharge planning: locked memory care facility once conservatorship finalized.

Geriatrics Checklist

• Mind: CAM negative; MoCA 2/30; last BM 12/06/25.
• Tethers: Lap belt in use for elopement risk.
• Vision/Hearing: Glasses at bedside.
• Mobility: Ambulate as tolerated; encourage OOB to recliner.
• Medications: Reviewed; high-risk meds minimized; psych meds per protocol.
• Matters Most: Code status – No Code; primary contact Conrad Strauch.
• Hospital Issues: Diet consistent carbohydrate + supplements; VTE prophylaxis with Eliquis.

Rationales for New Items

• HTN management: Tight BP control reduces stroke and cardiac risk in T2DM.
• Geriatrics checklist: Ensures comprehensive care addressing cognition, mobility, safety, and goals of care.
• Lap belt use: Prevents elopement while minimizing restraint time for dignity.

Quick Note 2

Patient intermittently agitated; elopement precautions in place (lap belt PRN). CAM negative; MoCA 2/30. BP elevated (SBP 150–170s); GDMT continued. Out of bed in recliner when calm. On Depakote, trazodone PRN; olanzapine PRN available. Cardiac meds per GDMT; electrolytes monitored. Diet cardiac consistent carbs with supplements; calorie intake tracked. Last BM 12/06. Awaiting conservatorship for discharge planning. No acute distress noted.

Case 3:

Situation:
69 y/o male with complex PMHx (HFrEF, prior DVT/PE, Afib not anticoagulated due to falls and prior spinal cord hemorrhage, CAD on Plavix, T2DM, HTN, HLD, COPD on 2 L NC, chronic osteomyelitis, CML s/p allo stem cell transplant with chronic GVHD, BPH) admitted for hallucinations/disorientation, initially in MICU for septic shock requiring vasopressors, now on floor. Current issues: chronic OM, worsening wheezing, glycemic control, wound care, and multiple comorbidities.

Background:

• HFrEF (EF improved to 50–55%)
• Afib with RVR during admission; now rate-controlled on digoxin and metoprolol
• COPD/emphysema on home O₂
• Chronic osteomyelitis of ankle/foot; MRSA and pseudomonas
• CML s/p stem cell transplant (2015), chronic GVHD
• T2DM (A1c 9.8), HTN, HLD
• Chronic pain, constipation, GERD
• PICC in place for anticipated IV antibiotics
• Code: No Code

Assessment:

• Sepsis (resolved): Initially septic shock; now stable, source likely chronic OM.
• OM of ankle/foot: MRSA/pseudomonas; podiatry following; bone biopsy planned after antibiotic holiday.
• Respiratory: Worsened wheezing; hypercarbic RF; on baseline O₂; duonebs PRN; prednisone taper ongoing.
• Afib: Rate-controlled; on digoxin and metoprolol; goal K >4, Mg >2.
• HFrEF: EF improved; GDMT continued except Jardiance and spironolactone held.
• T2DM: On high-dose correction scale; basal/bolus insulin regimen adjusted.
• Delirium: Improving; mental status baseline.
• Constipation: On bowel regimen; last BM 12/5.
• Pain: Managed with oxycodone and OxyContin; tylenol PRN.
• Nutrition: Dysphagia diet + supplements; PT/OT involved.
• Access: PICC maintained for IV antibiotics post-biopsy.

Recommendation:

• Continue wound care and prep for bone biopsy; maintain antibiotic holiday unless fever/hypotension occurs.
• Monitor respiratory status; administer duonebs PRN; continue prednisone taper.
• Maintain rate control for Afib; monitor electrolytes.
• Continue GDMT for HF; reassess diuretic needs after CXR.
• Strict glucose monitoring; adjust insulin as needed.
• Maintain PICC for anticipated IV antibiotics.
• Monitor mental status and electrolytes; encourage PO intake to address hemoconcentration.
• Discharge planning: wound vac setup, outpatient podiatry, neurology follow-up for ventriculomegaly, ID for antibiotic plan.

Rationales

• Antibiotic holiday before biopsy: Improves diagnostic yield for OM cultures.
• Duonebs and prednisone: Reduce bronchospasm and inflammation in COPD exacerbation.
• Electrolyte monitoring: Prevent arrhythmias in Afib and HF.
• Strict glucose control: Prevent infection complications and optimize wound healing.
• Wound vac therapy: Promotes granulation and reduces infection risk.
• PICC maintenance: Ensures reliable access for prolonged IV therapy.

Quick Note:

Patient alert, oriented; on 2 L NC with SpO₂ 99%. Wheezing noted; duoneb given per RT. PICC intact; site clean/dry. Wound care performed; OM site dressed per protocol. Foley not present; voiding spontaneously. On insulin regimen; BG monitored closely. Pain controlled with scheduled OxyContin and PRN oxycodone. Turn/reposition Q2 hrs; heels offloaded. Dysphagia diet with supplements; PO intake encouraged. No acute distress noted.

Case 4

Situation:
95 y/o male with dementia, HTN, HLD admitted for poor PO intake and unresponsiveness, found to have sepsis secondary to pneumonia, hypernatremia, and AKI. Initially in S/U for antibiotics and O₂, now improved and transferred to Cooney. Course complicated by MSSA bacteremia, extensive RLE DVT, and bilateral PE. Pending goals-of-care (GOC) discussion with family due to poor prognosis.

Background:

• Dementia, HTN, HLD
• Severe sepsis from MSSA bacteremia and aspiration pneumonia
• Acute respiratory failure (improved)
• Hypernatremia and AKI (improving)
• Extensive RLE DVT and bilateral PE
• Severe protein-calorie malnutrition
• Toxic metabolic encephalopathy improving
• Code: No Code

Assessment:

• Sepsis/MSSA bacteremia: On cefazolin and ampicillin-sulbactam; ID following.
• Aspiration pneumonia: NPO per SLP; aspiration precautions in place.
• Hypernatremia: Improving on D5½NS; BMP daily; strict I/O.
• DVT/PE: On heparin gtt; intermediate-low risk PE.
• Encephalopathy: Improving but baseline dementia persists.
• AKI: Pre-renal; improving with fluids.
• Malnutrition: NPO; thiamine/folate supplementation; plan for enteral nutrition when safe.
• GOC: Family discussion ongoing regarding hospice/CMO.

Recommendation:

• Continue antibiotics per ID; monitor cultures.
• Maintain aspiration precautions; NPO until cleared by SLP.
• Continue heparin gtt for DVT/PE; monitor for bleeding.
• Continue D5½NS; monitor sodium and renal function.
• Engage family for GOC; document decisions promptly.
• Nutrition: prepare for enteral feeding once cleared; continue supplements.
• Monitor mental status and respiratory status closely.
• CMO

Rationales

• Antibiotics: Target MSSA bacteremia and aspiration pneumonia to prevent septic progression.
• Aspiration precautions/NPO: Reduce risk of recurrent pneumonia.
• Heparin gtt: Prevent clot propagation and PE complications.
• IV fluids: Correct hypernatremia and support renal recovery.
• Nutrition support: Prevent further catabolic state and improve healing.
• GOC discussion: Align care with patient/family wishes given poor prognosis.

Quick Note:

Patient lethargic but arousable; on room air with stable SpO₂. NPO per SLP; aspiration precautions maintained. Receiving D5½NS at 150 mL/hr; strict I/O monitored. On heparin gtt for DVT/PE; no bleeding noted. Antibiotics continued per ID. PICC not present; PIV intact. Last BM 12/03. Family meeting pending for GOC/hospice discussion. No acute distress noted.

Case 5

Situation:
72 y/o male with COPD, OSA on CPAP, alcohol use disorder (hx complicated withdrawals/seizure), HTN, prior CVA (2024), carotid stent, and prior DVT presented with shortness of breath and alcohol intoxication. Admitted for acute COPD exacerbation, AKI, and anxiety likely related to alcohol withdrawal. Currently hemodynamically stable on the floor.

Background:

• COPD on home inhalers
• OSA on CPAP
• Alcohol use disorder with prior severe withdrawals
• HTN, HLD, prior CVA with carotid stent
• T2DM (A1c 6.5)
• Recent echo normal
• Code: Full Code

Assessment:

• COPD exacerbation: Acute hypoxic respiratory failure; received IV Lasix and Solu-Medrol in ED; now on prednisone taper, inhalers, and duonebs PRN.
• Chest pain: Likely anxiety-related; EKG stable, troponins flat.
• Anxiety: Likely iso alcohol withdrawal; on fluoxetine; trazodone PRN started.
• Alcohol withdrawal/intoxication: CIWA protocol with PRN diazepam; thiamine and folate supplementation; declined addiction medicine.
• AKI: Likely prerenal; improving after fluids; strict I/O and PO intake encouraged.
• HTN/HLD/CVA hx: Continue amlodipine, rosuvastatin, ASA, clopidogrel.
• T2DM: Continue Jardiance; monitor BG.
• Mobility: PT/OT consulted.

Recommendation:

• Continue prednisone 40 mg daily x 5 days; monitor respiratory status and attempt O₂ wean to goal SpO₂ 88–92%.
• Continue inhalers (Symbicort, Spiriva), duonebs PRN, albuterol PRN.
• Maintain CIWA protocol; monitor for withdrawal complications.
• Encourage PO intake; monitor renal function and electrolytes.
• Continue cardiac meds and DAPT; monitor BP and neuro status.
• Discharge planning: outpatient pulmonary follow-up for PFTs and possible CT; addiction medicine referral if patient agrees.

I&R

• Prednisone and inhalers: Reduce airway inflammation and improve airflow in COPD exacerbation.
• CIWA protocol: Prevent severe withdrawal complications (seizures, delirium tremens).
• O₂ weaning: Avoid hyperoxia and CO₂ retention in COPD patients.
• Strict I/O and hydration: Support renal recovery and prevent worsening AKI.
• DAPT and statin: Secondary prevention for CVA and carotid stent.

Quick Note:

Patient alert, oriented; on supplemental O₂ with SpO₂ 92%, goal 88–92%. Wheezing noted; duoneb administered per RT. CIWA protocol ongoing; diazepam PRN available when needed. On prednisone taper; inhalers continued. Encouraged PO intake; strict I/O monitored. Pain managed with Tylenol PRN. PT/OT consulted; patient ambulated with assistance. No acute distress noted.