Field Note for April 13th 2026

Room 1 

Name: I
Date of adm: 4/9/26 (Day 4) 
Age: 84 
Gender: Male 
Code Status: Full
Chief Complaint (CC): Mechanical fall with head strike, wrist & ankle pain 
Isolation Status: None 
Any allergies: NKDA 

Diagnosis: Left triquetral avulsion fracture (splinted) 

• Right ankle sprain (wrapped) 

• Difficulty ambulating 

PMHx: Dementia, HTN, HLD, CKD3, CAD, HFrecEF, severe AS s/p TAVR, AFib s/p TEE/DCCV, SSS s/p PPM, nephrolithiasis s/p nephrectomy, BPH, gout 

Current surgery: None 
Dressing Type: Wrist splint, ankle wrap 
Bed Type: Med‑Surg 
Rhythm Type: AFib (on Xarelto) 

Neuro: A&Ox2, Dementia baseline, no LOC, head CT negative 
Respiratory: RA 
Cardiovascular: CHF, AFib, cards following; on PO Lasix 
GI: Regular diet (Halal no beef/pork) 
GU: BPH, voiding 
ACHS: No 
Diet: Regular, Halal (no beef/pork) 
IV Accesses: PIV 
M/S Activities: Difficulty ambulating, high fall risk 
Skin/Wounds: Intact 
Dressings: Wrist splint, ankle wrap 
Vital Signs Time: Routine 

Orders and Follow‑Ups: Pain control, PT/OT, duplex RLE negative 
Discharge Disposition: Pending mobility / placement 
Imaging: CTH negative, ankle/wrist imaging as above 
VTE Prophylaxis: Xarelto 
Pain Management: Tylenol, tramadol PRN, lidocaine patch 
Any questions: Rehab vs SNF? 

Room 2 

Name: S
Date of adm: 4/11
Age: 102
Gender: Male 
Code Status: DNR 
Chief Complaint (CC): Watery diarrhea, fever 
Isolation Status: Contact – Rotavirus (4/12/26) 
Any allergies: NKDA 

Diagnosis: 

• Rotavirus diarrhea 

• UTI (Proteus) 

PMHx: Severe AS s/p TAVR (3/20/26), PPM, PAF, CAD s/p PCI, HTN, HLD, BPH w chronic Foley, CKD, RCC s/p partial nephrectomy, prior SAH 

Current surgery: None 
Bed Type: Med‑Surg 
Rhythm Type: SR with LBBB, prolonged QTc 

Neuro: A&Ox2 
Respiratory: RA 
Cardiovascular: AFib on Eliquis; BP stable 
GI: Watery diarrhea, rotavirus + 
GU: Chronic Foley 
ACHS: No 
Diet: DASH pending swallow screen 
IV Accesses: PIV 
M/S Activities: Fall risk 
Skin/Wounds: Intact 

Orders and Follow‑Ups: 

• Continue CTX for UTI 

• Stool studies / contact iso 

• IVF, trend BMP/CBC 

• Hold diuretics/ARB 

• Urology f/u for 3.8 cm L renal mass 

Discharge Disposition: Pending diarrhea/AKI resolution 
Imaging: CTAP – cystitis?, L renal mass 
VTE Prophylaxis: Eliquis 
Pain Management: Tylenol PRN 

UPDATE: Back on LR IVF@75/HR

 

Room 3 
Name: P
Date of adm: 4/12
Age: 96
Gender: Female 
Code Status: Full code 
Chief Complaint (CC): Severe thoracic back pain, inability to ambulate 
Isolation Status: None 
Any allergies: Advil, aspirin, PCN (GI upset) 

Diagnosis: Acute on chronic thoracic back pain 

PMHx: Osteoporosis, OA, HTN, HLD, mood disorder 
Bed Type: Med‑Surg 
Rhythm Type: NSR 

Neuro: A&Ox2, confuse 
Respiratory: RA 
Cardiovascular: Stable 
GI: Regular bowel regimen 
GU: Voiding 
ACHS: No 
Diet: DASH/TLC + Ensure 
IV Accesses: PIV 
M/S Activities: Limited by pain, OOB x2 to chair 
Skin/Wounds: Intact 

Orders and Follow‑Ups: Pain control, PT/OT 
Discharge Disposition: Pending pain/mobility 
Imaging: Prior trauma scan negative for acute injury 
VTE Prophylaxis: Enoxaparin 
Pain Management: Tylenol, oxy PRN, lidocaine 
 

Room 4 
Name: R
Date of adm: 4/10
Age: 66
Gender: Female 
Code Status: Full code 
Chief Complaint (CC): Progressive LE weakness, paresthesias 
Isolation Status: None 
Any allergies: NKDA 

Diagnosis: 

• Suspected Guillain‑Barré Syndrome 

• Hypokalemia 

PMHx: Obesity, chronic knee pain, gastric sleeve 

Current surgery: None 
Bed Type: Med‑Surg 
Rhythm Type: NSR 

Neuro: A&Ox4, Bilateral LE weakness (L>R) 
Respiratory: RA 
Cardiovascular: Stable 
GI: Regular diet 
GU: Voiding 
ACHS: No 
IV Accesses: PIV 
M/S Activities: Limited mobility 

Orders and Follow‑Ups: IVIG x5 days, neuro eval 
Discharge Disposition: Pending strength recovery 
Imaging: Pending workup 
VTE Prophylaxis: Enoxaparin 
Pain Management: Tylenol 

Update: IVIG 4/5

Room 7 
Name: A
Date of adm: 4/12
Age: 68 
Gender: Female 
Code Status: Full code 
Chief Complaint (CC): Bright red blood per rectum 
Isolation Status: None 
Any allergies: NKDA 

Diagnosis: Lower GI bleed likely diverticular 

PMHx: Vertigo, diabetes 

Bed Type: Med‑Surg 

Neuro: A&Ox4 
Respiratory: RA 
Cardiovascular: Stable Hgb 
GI: Rectal bleeding resolved 
Diet: Regular 

Orders and Follow‑Ups: Monitor H/H, high‑fiber diet 
Discharge Disposition: Likely home 
VTE Prophylaxis: SCDs 
Pain Management: Tylenol PRN 
Any questions: GI follow‑up? 

Room #: 11 
Name: T
Date of adm: 4/12/26 (Day 1) 
Age: 54 
Gender: Male 
Code Status: Full code 
Chief Complaint (CC): LLE pain/swelling 
Isolation Status: None 
Any allergies: NKDA 

Diagnosis: Recurrent LLE DVT and Cellulitis 

PMHx: HTN, HLD, gout, recent PE 

Bed Type: Medsurg 

Neuro: A&Ox4 
Respiratory: RA 
Cardiovascular: On heparin gtt d/ced
GI: Regular diet 
GU: Voiding 

Orders and Follow‑Ups: Heparin drip, heme/onc following 
Discharge Disposition: Pending anticoag plan 
VTE Prophylaxis: Therapeutic heparin 

Update: Home lovenox self-administered.