CASE STUDIES

Difficult inpatient-stay denials

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CLINICAL SUMMARY: Ankle Injury with Complex Medical History

A 68-year-old patient arrived in the ER with severe pain, numbness and injury to her left ankle due to a fall at home. The patient had metastatic ovarian carcinoma and was undergoing chemotherapy with carboplatin and paclitaxel. Paclitaxel dose was reduced prior to this incident due to worsening peripheral neuropathy. The last chemotherapy session was six days prior to the fall. The patient’s medical history included obesity, type 1 diabetes mellitus with an insulin pump, hypertension, hyperlipidemia, hypothyroidism, COPD, and asthma (using O2 at home). Labs were WBC 6.74; Hgb 7.6, 7.2; PLT 222; Na 133, 135; K 4.6; BUN 40, 40; Cr 1.08; and GLU 101-206.

An x-ray in the ER showed a complex fracture, dislocation of the left ankle for which the patient underwent a closed reduction and application of a splint.

CLINICAL SUMMARY: Alcohol Withdrawal

One day after being released from the hospital for alcoholic intoxication and suicidal ideation, a 53-year-old male arrived in the Emergency Department with alcohol withdrawal with seizures and hyponatremia. The patient had a history of alcohol abuse and multiple admissions for withdrawal, diabetes along with a left foot cellulitis diabetic wound, hypertension, anxiety, and depression. The patient was transported to the hospital after a four-minute seizure during which he fell and bit his tongue. He confirmed that he had not been taking his seizure medication and reported drinking heavily – 2-3 cases of beer per day. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was determined to be 16.

The patient continued treatment on the second day in the hospital with continued Haldol as well as fall precautions, seizure precautions and telemetry monitoring. The patient left the hospital on day 3 against medical advice.

CLINICAL SUMMARY: Alcohol Withdrawal + COVID-19

A 19-year-old patient arrived in the emergency room with alcohol withdrawal symptoms and subsequently tested positive for COVID-19. The patient had a past medical history that included anxiety, depression, alcohol withdrawal seizures, hallucinations, alcohol abuse and dependence, and hypertension. He reported passive suicidal ideations without a plan. The patient, who reportedly drank about a liter of whiskey a day, was seeking an alcohol detox program and had a history of delirium tremens. Lab results showed an ETHO breath test of 0.138 and Clinical Institute Withdrawal Assessment (CIWA) 3-23 with additional lab results that showed the following: sodium 134, potassium 4.1, creatinine 0.74, magnesium 2.1, ALT 205, AST 147, total bili 0.8, lipase 160, white count 4.2, hemoglobin 17.4, and platelets 181. Urine drug screen was negative. The patient was treated with the CIWA protocol (Serax tapering dose of benzodiazepine) and also received Haldol.

The patient continued treatment on the second day in the hospital with continued Haldol as well as fall precautions, seizure precautions and telemetry monitoring. The patient left the hospital on day 3 against medical advice.

CLINICAL SUMMARY: Multiple Sclerosis

A 79-year-old female with a history of multiple sclerosis, hypertension, motion sickness, neuropathy, osteoporosis, renal insufficiency, UTIs arrived at the hospital feeling weakness in her lower extremities after a fall at home. She notably had received a COVID booster shot on the same day that she developed weakness and was unable to walk on her own. The patient was admitted and received a neurology consult for evaluation of what treating physicians thought could be a possible MS flare up. An MRI of the brain, cervical, and thoracic spine showed no active lesions except for a questionable enhancing small lesion posterior to the C7 vertebral body. All labs were normal, and the patient resumed her home medication regimen.

On the following day, the patient’s lower extremity weakness improved. Neurology obtained a carotid ultrasound to rule out all possible causes and found no significant carotid artery stenosis that may have contributed to her acute presentation. The patient received physical therapy and was able to ambulate around the room with no weakness in the extremities. Patient was discharged on the second hospital day to continue with her routine medications.

CLINICAL SUMMARY: Unstable Angina TIMI 3

A 67-year-old male arrived in the Emergency Room complaining of chest pain located at the center of the chest radiating to the left shoulder and neck. The patient felt a sensation of pressure and had shortness of breath. The patient had a past medical history of diabetes, hypertension, hyperlipidemia, OSA and had undergone a lumbar spine fusion. The patient also had abnormal results from a recent stress test and was scheduled for a cardiac angiogram. ER physicians administered nitroglycerin which relieved the pain.

CLINICAL SUMMARY: Chest Pain, Non-Cardiac

A 54-year-old male patient arrived in the emergency room with left-sided chest pain and left neck pain that had been occurring all day and intermittently for the previous 6 months. He rated the severity of pain at the time as an 8/10. The patient reported feeling short of breath on exertion with nausea, vomiting, dizziness, and weakness. The patient denied melena, fever, hearing loss, leg swelling, dysuria, gait problems, pallor headache or confusion. He took an aspirin twice on the day of admission. The patient had a history of hypertension, dyslipidemia, asthma, arrhythmia and underwent an incomplete stress test in the previous year. He also reported having 1-2 drinks daily and was vaccinated for COVID.

CLINICAL SUMMARY: Bilateral Pneumonia

A 23-year-old nonverbal female patient arrived in the emergency department with her parents who said she had a fever and heavy breathing since the morning. The patient’s medical history included Lennox-Gastaut Syndrome, severe mental retardation, seizure disorder, recurrent aspirations, recurrent pneumonia and vagal nerve stimulator. Her parents said she had been suffering with flu-like symptoms for the previous week. However, she had no cough, vomiting or abdominal pain. It is noted that the patient was not physically able to cough. She had been vaccinated for COVID-19 and received a booster as well as the influenza vaccine.

CLINICAL SUMMARY: Diabetes

This case study involves a 54-year-old female patient with a past medical history of type I diabetes, diabetic gastroparesis, nephrolithiasis, hypothyroidism, hypertension, and traumatic brain injury. She arrived in the ER out of concern for diabetic ketoacidosis (DKA). The patient was hospitalized for DKA one month before this admission. She had been sick with nausea, vomiting, upper abdominal pain similar to prior gastroparesis attacks and was unable to take her insulin for several days. On the day of admission, she started noting blood sugars greater than 400 on her monitor at home, as well as a very dry mouth, and the inability to stay hydrated. The patient had no fever, chest pain, shortness of breath, or cough. In the ER, there was generalized abdominal tenderness and tenderness in the right upper quadrant and epigastric area. There was no rCVA tenderness, guarding or rebound. Her vital signs were as follows: temperature max 100 degrees F,  pulse 102-126, respiratory rate 16-20, blood pressure 112/63, oxygen saturation 100% on room air. A chest x-ray was unremarkable. Her labs had the following results: WBC 14.54, Hgb 15.3, platelets 494, Na 128 (135 corrected for glucose 464), K 5.2, CO2 11, BUN 21, Cr 1.32, osmolality 289, VBG pH 7.11, β-OH butyrate 91.30, Glucose 76-493. Urine analysis: + glucose, + ketones.

CLINICAL SUMMARY: COPD

This case involved an 83-year-old female patient with a known history of chronic COPD on 4L supplemental oxygen via nasal cannula, DVT, gout, multiple falls, hypertension, and anxiety. She arrived in the emergency department with complaints of shortness of breath that had gotten worse over the previous 24 to 48 hours, especially on exertion. She said she was out of breath earlier in the day with self-measured oxygen saturation in the low 70’s. She increased her oxygen to 5L without significant improvement. She did not have a cough, fever, chills, nausea, or any vomiting. Patient also reported intermittent chest pain under the left breast that felt like ‘something catches’ and was impacting her breathing.

CLINICAL SUMMARY: Sepsis

This case involved a 74-year-old patient who presented with chills and a temperature of 103°F. The patient had a past history of hypertension, arthritis, and right total shoulder replacement in January 2021. Chest x-ray showed coarse perihilar and interstitial markings, likely viral or reactive. A CTA chest was negative for pulmonary embolism or acute pulmonary disease. A urine test was nitrate positive with trace leukocyte esterase. Blood cultures were drawn, and urine was sent for culture.

CLINICAL SUMMARY: NSTEMI

This case centers around a 59-year-old female who arrived at the hospital ER with ‘tightness’ and left-sided chest pain that began at rest. The patient said she has had similar pain several times over the last month. She suddenly awoke with severe left lower quadrant pain, which is a chronic issue for her IBS/colitis, that night. Shortly after her abdominal pain started, she reports left-sided chest discomfort with associated nausea. She said she has a large amount of stress at home.

CLINICAL SUMMARY: Suicidal Ideation

A 47-year-old patient was admitted for an intentional drug overdose, suicidal ideation, anxiety depression and alcohol abuse. Past medical history showed the patient suffered from bipolar disorder, anxiety depression panic attacks. The ER report stated the patient arrived via EMS after taking one bottle of benzodiazepines along with alcohol but was alert. The patient was admitted to a step-down unit with 1-on-1 sitter for suicidal and seizure precautions.

CLINICAL SUMMARY: Post C-section

A 36-year-old new mother with a recent C-section was admitted after an ER visit due to shortness of breath occurring since the delivery of her child and drainage from her surgical incision. The patient had a significant past medical history of morbid obesity, asthma, and sleep apnea. The physician summary showed the patient had acute toxic respiratory failure due to asthma exacerbation.

CLINICAL SUMMARY: Acute Diverticulitis

A 69-year-old female with past medical history of atrial fibrillation, aortic/mitral valve replacement, chronic anticoagulation, hypertension, hyperlipidemia, diabetes mellitus, neuropathy, GERD, COPD. The patient was admitted to the hospital with chief complaint of abdominal pain and bright red blood per rectum. The CT of the abdomen pelvis showed diffuse colonic bowel wall thickening compatible with colitis/diverticulitis.

CLINICAL SUMMARY: Cardiac Ablation

A 79-year-old patient was scheduled to have an elective cardiac ablation which went well, but the patient developed hypotension post procedure. In a previous ablation procedure, the patient had a similar response post ablation with hypotension requiring several days of hospitalization. The most recent hypotension required Levophed. The patient was also diagnosed with a UTI prior to the ablation and antibiotics were on-going.

CLINICAL SUMMARY: Short Stay Policy

Patient was admitted to the hospital for orbital cellulitis IV treatment. The patient presented with left eye redness and pain with movement, especially over the left gaze. There was no history of recent trauma. Maxillofacial CT showed mild left globe proptosis with preseptal edema, mild rectus enlargement with possible surrounding fatty stranding. As per ophthalmology patient was thought to have possible orbital cellulitis and placed on broad-spectrum IV antibiotic therapy. The patient, who also had a history of drug abuse, decided to leave against medical advice while being treated.

CLINICAL SUMMARY: TIMI Score

An 80-year-old patient with a past medical history of atrial fibrillation, arthritis, congestive heart failure, COPD, hyperlipidemia, hypertension, history of PE, pacemaker GERD, arrived in the Emergency Department with chest pain which had been occurring for a week.

CLINICAL SUMMARY: Hemodialysis

A 48-year-old male patient was admitted for fluid overload with symptoms of shortness of breath and weakness due to missing hemodialysis appointments. The patient had a significant past medical history of hypertension, dyslipidemia, atrial fibrillation, end-stage renal disease and was on hemodialysis three times a week. When admitted, the patient was also complaining of a recurrent abscess in the mouth previously drained but not treated due to a missed follow-up. The patient was admitted for incision and drainage of the abscess and IV antibiotics.

CLINICAL SUMMARY: Oropharyngeal Cancer and Alcohol Withdrawal

Patient with SCC oropharyngeal cancer was admitted to the hospital with alcohol withdrawal. No beds were available at a detox center; therefore, the patient was brought to the Emergency Department for help.

CLINICAL SUMMARY: Asthma and High BMI

Patient with a history of asthma and a high BMI was admitted with asthma exacerbation and a wound infection.

CLINICAL SUMMARY: Total hip arthroplasty

A 66 year-old patient undergoing total hip arthroplasty. The patient received an ASA score of 3, having multiple comorbidities including asthma and need for postoperative supplemental oxygen therapy.

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