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51 year old with HTN presents with acute lower chest / epigastric pain in the setting of elevated liver enzymes and low K+. Work-up so far is unrevealing for a clear etiology.

Cardiac testing reviewed — troponin ×3 negative, BNP normal, ECG NSR with poor R-wave progression but no ischemic changes, CXR unremarkable. Constellation of symptoms is more consistent with an acute GI process than ACS.

Replete K+ to goal 3.5–4.0; recheck BMP with each replacement. Continue home anti-HTN regimen with in-hospital goal 130/80. Trend LFTs and obtain RUQ ultrasound to work up the transaminitis.

Cholesterol panel is abnormal — agree with initiating moderate-intensity statin (atorvastatin 40 mg) prior to discharge and arranging outpatient lipid follow-up.

If chest pain recurs or evolves, obtain repeat ECG and troponin and page Cardiology. If symptoms persist without a clear GI diagnosis, an outpatient stress test is reasonable to fully rule out atypical CAD.

Also: reinforce tobacco cessation counseling and confirm ASA 81 mg is appropriate given current bleeding risk.

— Cardiology Service

Likely due to poor oral intake and inadequate/missed dosing of DDAVP (home dose 2 mcg SQ BID).

Free water deficit ≈ 5.4 L; weight 67 kg. AM osmolality 334, Na 169, urine Na pending.

Avoid rapid correction (>10 mmol/L / 24 h). Continue Q6H BMP; UA with specific gravity and osmolality; strict I&Os with foley for accurate output.

If DDAVP becomes available, start 2 mcg IV q8h with Na reassessment. Otherwise re-check Na q6h on vasopressin 10 U SQ TID.

If Na fails to correct on vasopressin + free water replacement, agree with transfer for higher level of care.

Also: hypothyroidism — check TSH, FT4. Continue levothyroxine 150 mcg daily.

— Endocrinology Service

73 year old with poorly controlled DM2 (A1c 9.1), BLE amputations and a chronic sacral decubitus, now with leukocytosis and a positive UA. Primary concern is sacral osteomyelitis with a concurrent urinary source of infection in an immunocompromised host.

Imaging review: CT shows R renal pelvis stones (largest 6 mm) with no drainable collection. Recommend MRI pelvis with and without contrast to evaluate the sacrum for osteomyelitis and any deep abscess. If MRI is limited by hardware, plain films plus a tagged WBC scan are a reasonable alternative.

Continue empiric ceftriaxone + clindamycin pending cultures. De-escalate once blood and wound cultures return — if MSSA, transition to cefazolin; if MRSA, vancomycin with trough monitoring. Duration will be 6 weeks IV from the date of adequate source control if osteomyelitis is confirmed.

Optimize glycemic control — A1c 9.1 with glucose 367 will impair both wound healing and antibiotic penetration. Basal-bolus insulin while inpatient with endocrine input as needed.

Wound care consult for a bedside debridement plan and offloading strategy. Urology to address nephrolithiasis after the acute infection is controlled.

If the patient decompensates, cultures grow a resistant organism, or MRI reveals a drainable collection, escalate to broader coverage (e.g. vancomycin + piperacillin-tazobactam) and involve IR / Surgery.

— Infectious Disease Service

Subacute R MCA territory infarcts most likely secondary to R ICA occlusion via artery-to-artery embolization, less likely watershed from intermittent hypotension. Symptoms present 5–7 days — outside the acute intervention window for thrombolytics or thrombectomy.

Vascular risk factors: active tobacco use, untreated HTN, unknown lipid and glycemic status. Loaded with ASA + Plavix in the ED, which is appropriate.

Plan: continue DAPT (ASA 81 + Plavix 75) × 21 days then ASA monotherapy, high-intensity statin (atorvastatin 80 mg), HbA1c + fasting lipid panel, TTE with bubble study, and telemetry for at least 24 hours to rule out AFib.

Permissive HTN to maintain perfusion distal to the known ICA occlusion — goal SBP >140 and DBP >90 while symptomatic. Support with IVF as needed and avoid antihypertensives unless SBP >220 or evidence of end-organ injury.

Neurochecks Q2H with a stat non-contrast CT for any change. PT / OT / SLP eval. Urgent vascular surgery consultation for consideration of revascularization after discharge. Outpatient dilated ophthalmology for the reported blurred vision.

Coordinate with hospitalist for alcohol withdrawal prophylaxis — thiamine, folate, CIWA — as this can confound neuro exam. If exam worsens or new deficits emerge, repeat imaging and contact Vascular Neurology at KU for transfer.

— Neurology Service

66 year old with SLE on maintenance prednisone 5 mg daily, admitted with a complicated UTI. Presentation is more consistent with active infection than a true SLE flare, given normal CBC and preserved renal function.

Confirm disease activity: check dsDNA, C3, C4, ESR, and CRP to trend against infection. Normal complements and dsDNA alongside normal CBC and GFR would be reassuring against active lupus.

Screen for renal involvement with a UA and spot protein-to-creatinine ratio. Lupus nephritis is less likely with a normal GFR and bland sediment, but a baseline is useful for outpatient follow-up.

Avoid escalating immunosuppression during active infection. Low complements can reflect active SLE but are also depressed by infection, and elevated dsDNA can correlate with lupus nephritis — interpret in context.

For MSK symptoms, reasonable to increase prednisone to 15 mg daily × 1 week, then taper by 2.5 mg weekly until back to baseline, provided the pain responds within 24–48 hours. Avoid higher doses given the active infection and absence of organ involvement.

DMARDs (e.g. hydroxychloroquine) should not be initiated inpatient — this requires full outpatient rheumatology evaluation with baseline ophtho screening. Please arrange outpatient rheumatology follow-up within 4 weeks of discharge.

— Rheumatology Service