Comprehensive Inpatient Medical Rounds and Case Management Notes

Post-Operative Abscess and Infectious Disease Workup

• Patient Profile & Presentation:

  • $49\,\text{year old}$ female patient with a history of intravenous drug use (IVDU) and heart failure.

  • Currently on post-operative day 2 ($\text{POD 2}$) following incision and drainage ($\text{I\&D}$) of a left arm abscess.

• Surgical & Physical Examination:

  • Left arm is clinically stable and well-perfused.

  • No signs or symptoms of compartment syndrome.

  • Full motor function preserved across all extremities.

• Infectious Disease & Antibiotic Management:

  • Pain management and antibiotic therapy are ongoing based on Infectious Disease ($\text{ID}$) recommendations.

  • Total antibiotic course planned for $7\,\text{days}$, subject to clinical progress.

  • Clindamycin therapy has been discontinued.

  • Patient remains on IV vancomycin alongside home cardiac medications.

• Diagnostic & Serology Workup:

  • Infective Endocarditis ($\text{IE}$): Clinical suspicion for infective endocarditis remains low. Transthoracic echocardiogram ($\text{TTE}$) was evaluated due to IVDU history but determined to be low yield given direct local abscess etiology.

  • HIV: Negative screening result.

  • Hepatitis C: Positive Hepatitis C antibody and positive Hepatitis C $\text{RNA}$. Requires outpatient $\text{ID}$ follow-up for antiviral therapy and a repeat swab in $4\,\text{weeks}$ (to be obtained via primary care or local health department).

  • Hepatitis B: Administering Hepatitis B vaccination prior to discharge.

• Addiction Medicine & Social Work:

  • Addiction Medicine consult requested; patient is agreeable to evaluation.

  • Insurance coverage recently secured; patient is currently establishing primary care.

Complicated Metastatic Breast Cancer, Pneumonia, and Leptomeningeal Evaluation

• Patient Profile & Presentation:

  • Female patient (Miss Orin) transferred from an outside facility presenting with respiratory distress.

  • Primary Diagnoses: Hospital-Acquired Pneumonia ($\text{HAP}$), acute $\text{COPD}$ exacerbation, and metastatic breast cancer.

  • Supplemental Oxygen: Required $3\,\text{L/min}$ oxygen at the transferring facility.

• Oncology & Neurological Assessment:

  • $MRI$ imaging indicates concern for potential leptomeningeal disease spread.

  • Lumbar puncture ($\text{LP}$) scheduled today via Interventional Radiology ($\text{IR}$) as requested by Oncology.

• Gastrointestinal & Nutritional Management:

  • Inadequate oral intake; trialed Magic Cups without success. Offering Ensure today.

  • Intermittent nausea managed with Zofran.

  • Marinol increased to $3\,\text{times daily}$ ($\text{TID}$) to stimulate appetite and control nausea.

  • Zoloft dose evaluated/adjusted at $25\,\text{mg}$ (reduced from $50\,\text{mg}$) due to nausea.

• Intravenous Access & Complications:

  • Significant history of IV extravasation.

  • Required slow intravenous potassium repletion ($10\,\text{mEq}$ per $2\,\text{hours}$) to prevent line complications.

• Laboratory & Goals of Care:

  • $CBC$ and $CMP$ remain stable.

  • Blood cultures and smears negative to date (note: cultures drawn after initial antibiotic administration, including Levaquin).

  • Daughter actively involved in care; goals of care discussions ongoing regarding hospice transition (Windsor).

Advanced Limb Ischemia, Substance Misuse, and Chronic Conditions

• Ischemic Limb & Vascular Management:

  • Patient (Mr. Harris) presenting with severe upper extremity pain secondary to end-stage limb ischemia ("toast" vasculature).

  • Orthopedics and Vascular Surgery consulted; determined non-operable. Recommended non-procedural ischemic management.

  • Hemoglobin levels show a steady downward trend over a $2\,\text{day}$ monitoring window.

• Pain & Medication Weaning:

  • Currently on a Patient-Controlled Analgesia ($\text{PCA}$) pump.

  • Initiated weaning protocol using oral Oxycodone $5\,\text{mg}$ PRN (received $2\,\text{doses}$ overnight).

• Cognitive & Disposition Status:

  • Baseline intellectual impairment limits complex decision-making capacity; requires surrogate assistance to understand clinical consequences.

  • Requires placement at an extended care facility if surgical intervention is withheld.

• Comorbidities & Consults:

  • Chronic Clostridioides difficile (C. diff) infection; continuing oral fidaxomicin course through tomorrow.

  • Diabetes mellitus is currently well-controlled.

  • Hematology consultation requested.

Post-Sepsis Care, Transaminitis, and Biliary Pathology

• Post-Sepsis Presentation (20-Year-Old Female):

  • $20\,\text{year old}$ female (Ms. Ramsey) initially admitted meeting sepsis criteria.

  • Discharge delayed due to acutely rising transaminases.

• Symptom & Exam Profile:

  • Reports pleuritic chest pain alongside left upper quadrant ($\text{LUQ}$) and right upper quadrant ($\text{RUQ}$) abdominal/rib pain associated with deep breathing and trunk rotation.

  • Mild nasal congestion reported after attending a weekend football game; afebrile with no rashes or joint pain.

  • Bowel regimen for initial constipation caused rebound diarrhea; all laxative medications held.

  • Overnight vitals stable: heart rate in the $80\text{s}\,\text{bpm}$, peak systolic blood pressure $170\,\text{mmHg}$.

• Diagnostic & Laboratory Trends:

  • $BNP$: Decreased to $54\,\text{pg/mL}$ (down from $321\,\text{pg/mL}$).

  • Total Bilirubin: $1.4\,\text{mg/dL}$.

  • Alkaline Phosphatase: $270\,\text{U/L}$.

  • $CRP$: Decreased to $14\,\text{mg/L}$.

  • $RUQ$ Ultrasound: Demonstrated mild gallbladder wall thickening without biliary ductal obstruction or gallstones.

• Disposition:

  • Approved for discharge today with outpatient follow-up and repeat $CBC$/$LFT$ panel next week.

• Severe Alcohol Use Disorder Counseling:

  • Male patient consuming $1\,\text{L}$ of vodka daily.

  • Provided extensive addiction counseling; patient vehemently declined all addiction resources and recovery options.

Complex Oncology, End-Stage Care, and Soft Tissue Infection Management

• Crohn's Disease:

  • $26\,\text{year old}$ male (Fran) with active Crohn's disease admitted for inpatient management.

• Malignancy and Palliative Dialysis:

  • Male patient (Taylor) with non-operative urological malignancy complicated by severe recurrent $\text{UTI}$ and sepsis (currently on Day 5 of broad-spectrum antibiotics).

  • Physical Exam: Marked distension of the left flank and abdomen.

  • Leukocytosis attributed to underlying oncological disease.

  • Goals of Care: Patient and family (wife and son) coordinated with Palliative Care for home hospice transition, with explicit request to continue outpatient hemodialysis.

• Lower Extremity Cellulitis / Abscess with Substance Misuse:

  • Presentation with severe leg pain, focal erythema, and small subcutaneous abscesses.

  • Imaging reports confirm no evidence of osteomyelitis.

  • Urine Drug Screen ($\text{UDS}$): Positive for amphetamines and fentanyl.

  • Concomitant $\text{UTI}$ currently treated with Zosyn (planned step-down).

  • Pain Management: Scheduled acetaminophen and ibuprofen, plus Oxycodone $5\,\text{mg}$ every 6 hours ($\text{q6h}$) PRN; escalated to every 4 hours ($\text{q4h}$) PRN.

Rheumatoid Interstitial Lung Disease, Pulmonary Aspergilloma, and Viral Pericarditis

• Pulmonary Aspergilloma and Rheumatoid Arthritis:

  • Pathology: Large cavitary pulmonary aspergilloma (stable for $6\,\text{years}$) secondary to rheumatoid arthritis-associated interstitial lung disease ($\text{RA-ILD}$).

  • Symptoms: Severe, debilitating joint pain leaving patient bedridden for the past $4\,\text{weeks}$ (following prior complete disease remission).

  • Pharmacotherapy Interactions: Voriconazole discontinued by Rheumatology due to significant $\text{CYP}$ enzyme inhibition (increasing secondary drug exposure by up to $75\%$) and to expedite High-Resolution CT ($\text{HRCT}$) imaging.

  • Plan: Initiating Rituximab therapy in consultation with Pulmonology and Infectious Disease.

  • Hepatitis Serology: Anti-HBs negative, Anti-HBc positive, HBsAg negative (indicates prior exposed, non-active Hepatitis B infection).

  • Glycemic Control: Significant hypoglycemia experienced on Lantus; transitioned to sliding scale insulin. Adding scheduled prandial coverage ($2\,\text{units}$ before meals) for blood glucose levels around $165\,\text{mg/dL}$.

• Infectious Mononucleosis-Induced Pericarditis:

  • Clinical Presentation: Young adult presenting with neck lymphadenopathy, palpitations/tachycardia, and pleuritic chest pain.

  • Diagnostic Findings: Peripheral blood smear demonstrating atypical lymphocytes; positive mononucleosis viral testing. $LFT$ elevations showing stabilization/improvement.

  • Pharmacotherapy Regimen:

    • Colchicine: $0.6\,\text{mg}$ orally twice daily ($\text{BID}$).

    • Ibuprofen: High-dose anti-inflammatory therapy for $2\,\text{weeks}$ (or adjusted based on $\text{CRP}$ normalization).

    • Gastroprotection: Proton pump inhibitor ($\text{PPI}$) co-prescribed for gastropathy prevention.

  • Activity & Follow-Up Guidelines: Strenuous physical activity and heavy lifting restricted for $4\text{ to }6\,\text{weeks}$.

  • Outpatient Follow-Up: Lab recheck early next week; follow-up scheduled at internal medicine clinics (Medical Plaza / Archer Road / Spring Hill) per patient preference over Student Health.

Inpatient Bedside Procedures and Updated Transfusion Guidelines

• Paracentesis and Hepatic Encephalopathy Assessment:

  • Patient with tense abdominal ascites scheduled for Interventional Radiology ($\text{IR}$)/Radiology-guided paracentesis under Dr. Neil Howe and Dr. Griffin.

  • Physical examination includes evaluation for asterixis (flapping tremor) via wrist dorsiflexion.

• Blood Transfusion Guidelines in Specific Populations:

  • Review of updated societal statements regarding blood transfusions within specific patient communities (such as Jehovah's Witnesses).

  • Current guidelines support individualized care agreements allowing consenting patients to receive specific red blood cell components, fractionated products, or specialized recombinant therapies.