Notes

A 55-year-old male with past medical history significant for hypertension, hyperlipidemia, diabetes mellitus, obstructive sleep apnea on CPAP, GERD/gastritis, obesity, diverticulosis, and chronic daily alcohol use presented after a syncopal episode with fall while showering at home. Per patient report, he had been feeling dizzy, clammy, and overheated while on the commode prior to entering the shower, subsequently becoming lightheaded and losing consciousness with backward fall and head strike. EMS noted hypotension with systolic blood pressure in the 90s on scene. On arrival to the emergency department, patient was found to have a 4 cm posterior occipital scalp laceration which was stapled in the trauma bay, along with evidence of traumatic injury including C6 anterior superior endplate/spur fracture identified on CT cervical spine. Trauma surgery and neurosurgery were consulted. Initial trauma evaluation additionally demonstrated elevated lactate approximately 5.6, mild hyponatremia, hypokalemia, leukocytosis, and anion gap metabolic acidosis suspected secondary to volume depletion, alcohol use, and dehydration. CT brain demonstrated scalp laceration without acute intracranial abnormality, while CTA pelvis, chest imaging, and additional trauma imaging were otherwise negative for acute traumatic findings. Neurosurgical evaluation determined patient remained neurologically intact with Glasgow Coma Scale 15, without focal deficits, weakness, pelvic dysfunction, or significant neck pain, and conservative management was recommended. MRI cervical spine was discussed but declined by the patient. Cardiology and neurology were consulted for syncope evaluation. Cardiology assessment favored vasovagal situational syncope with intravascular volume depletion/dehydration in the setting of poor oral hydration, alcohol intake reportedly up to approximately 12 beers daily, and symptomatic episode occurring during bowel movement/straining and showering. Telemetry monitoring revealed no significant arrhythmias, EKG showed normal sinus rhythm, and serial troponins remained negative.

During hospitalization the patient was treated with aggressive IV fluid hydration, electrolyte replacement, telemetry monitoring, orthostatic vital sign assessment, thiamine and folic acid supplementation, and supportive care. Lactate and metabolic abnormalities improved with volume resuscitation. Leukocytosis was felt reactive in nature and trended down without evidence of acute infection. Hypokalemia and mild hyponatremia improved with replacement and hydration. The patient remained neurologically stable throughout admission without recurrent syncope, seizure-like activity, focal neurologic deficits, or worsening cervical symptoms. Neurosurgery recommended continued conservative management, fall precautions, incentive spirometry, DVT prophylaxis, physical therapy with mobilization as tolerated, and outpatient follow-up as needed for neurologic deterioration or worsening pain. Cardiology recommended continued hydration and precautionary measures for vasovagal syncope with no further inpatient ischemic workup indicated. Trauma service followed the patient’s scalp laceration and cervical fracture conservatively with plan for staple removal approximately two weeks after placement. The patient’s condition improved clinically with stabilization of blood pressure and resolution of acute symptoms, and he was discharged home in stable condition with instructions for hydration, alcohol reduction/cessation counseling, outpatient follow-up with primary care physician and specialists as indicated, continuation of home medications as appropriate, and strict return precautions for recurrent syncope, worsening neurologic symptoms, chest pain, or increasing neck pain.





A 48-year-old female with past medical history significant for anxiety, chronic alcohol use disorder, tobacco use, prior empyema with left pleural effusion status post left thoracotomy with decortication and pleurectomy in 2024, presented to the emergency department with progressively worsening generalized edema and anasarca over approximately two weeks extending from the lower extremities upward to beneath the breasts, associated with shortness of breath, chronic cough productive of clear sputum, and generalized fatigue. On presentation she met SIRS criteria with leukocytosis and elevated lactic acid approximately 5.38, prompting initiation of sepsis protocol and empiric IV antibiotics, although no clear infectious source was identified during hospitalization. Initial evaluation demonstrated elevated BNP, mild transaminitis, hepatosplenomegaly with diffuse hepatic steatosis, cardiomegaly with pulmonary vascular congestion, and generalized edema on CT imaging. CTA chest was negative for pulmonary embolism. Echocardiogram demonstrated preserved left ventricular ejection fraction approximately 57–60% with abnormal left ventricular geometry, grade 2 diastolic dysfunction, moderately dilated left atrium and right atrium, moderate mitral regurgitation with eccentric posteriorly directed jet, moderate tricuspid regurgitation, and elevated RVSP approximately 44 mmHg consistent with diastolic heart failure and volume overload. Cardiology was consulted and felt presentation was most consistent with multifactorial anasarca related to chronic liver disease and diastolic dysfunction rather than acute decompensated systolic heart failure. Gastroenterology was consulted for anemia, elevated liver function tests, alcohol use disorder, and concern for possible gastrointestinal bleeding. Workup revealed severe iron deficiency anemia with hemoglobin as low as 6.6 requiring PRBC transfusion with subsequent improvement to approximately 8.4. EGD and flexible sigmoidoscopy demonstrated no overt gastrointestinal bleeding, with biopsies obtained for celiac disease and H. pylori which were negative. Imaging and laboratory findings raised concern for alcoholic hepatitis and chronic liver disease with portal hypertension physiology secondary to chronic heavy alcohol use reportedly consisting of approximately 4–6 beers on most days of the week.

During hospitalization the patient was managed with IV diuresis, fluid and volume optimization, IV iron replacement with Venofer/Nulecit, proton pump inhibitor therapy, serial laboratory monitoring, alcohol cessation counseling, and multidisciplinary specialty evaluation by cardiology, gastroenterology, and hematology/oncology. Lactic acidosis improved and was felt likely secondary to volume overload state, hepatic dysfunction, and hypoperfusion rather than active infection, with leukocytosis also improving during admission. Liver ultrasound demonstrated hepatomegaly with diffuse fatty infiltration and mild gallbladder wall thickening without evidence of acute cholecystitis. Gastroenterology recommended strict alcohol abstinence, outpatient chronic liver disease evaluation including PT/INR and further liver workup, and consideration of future liver biopsy for definitive staging if clinically indicated. Hematology recommended continued outpatient iron replacement therapy and follow-up for management of severe iron deficiency anemia without evidence of hemolysis or active gastrointestinal blood loss. Cardiology recommended continuation of oral diuretic therapy for management of extravascular volume overload and noted patient remained otherwise stable from a cardiovascular standpoint without evidence of acute systolic heart failure exacerbation. The patient’s edema, respiratory symptoms, and laboratory abnormalities gradually improved with treatment. She remained hemodynamically stable at discharge and was discharged home in stable condition with close outpatient follow-up recommended with primary care, cardiology, gastroenterology, hematology/oncology, and addiction support services. She was counseled extensively regarding the necessity of complete alcohol cessation given evidence of probable alcohol-related liver disease and recurrent medical complications, and was instructed to return immediately for worsening dyspnea, chest pain, melena, hematemesis, worsening edema, confusion, jaundice, or any other acute clinical deterioration.



A 24-year-old female with history significant for bilateral cochlear implants with prior tympanic membrane and ear reconstruction surgeries, recent upper respiratory infection treated with Medrol Dosepak, and chronic recurrent headaches presented initially to an outside facility with acute onset dizziness, tunnel vision, gait instability, shaking episodes, intermittent jerking movements, slurred speech, and altered mental status beginning while shopping at Walmart. Family reported abrupt onset of symptoms without prior similar episodes. Initial evaluation at the outside hospital included CBC, CMP, urinalysis, urine drug screen, and CT/CTA imaging of the head and neck which demonstrated no cervical carotid or vertebral artery stenosis, no intracranial arterial occlusion or aneurysm, no dural venous sinus thrombosis, and no acute intracranial hemorrhage or mass effect. Imaging interpretation was significantly limited by artifact from bilateral cochlear implants, although asymmetric posterior white matter low attenuation was noted with concern raised for possible reversible encephalopathy in the appropriate clinical setting. The patient was transferred for further neurologic evaluation. On admission she remained afebrile, hemodynamically stable, and nontoxic appearing, though continued to complain of dizziness, gait instability, tunnel vision, intermittent headaches, and reluctance to ambulate secondary to fear of falling. Differential diagnosis remained broad and included acute metabolic encephalopathy, post-viral vestibular syndrome or labyrinthitis, vestibular neuritis, migraine-related phenomenon, demyelinating or inflammatory process, medication effect, functional neurologic disorder, and less likely cerebrovascular pathology given reassuring vascular imaging. Neurology was consulted and recommended continued neurologic monitoring, supportive care, and MRI evaluation if feasible, although imaging options were complicated by the patient’s cochlear implants. She was placed on telemetry monitoring with fall precautions, underwent PT/OT evaluation, received IV fluids, symptomatic management for vertigo and nausea, and electrolyte replacement for mild hypokalemia.

During hospitalization the patient’s symptoms gradually improved with supportive management. Neurology reviewed the available CT imaging and felt there was significant streak artifact from cochlear implants without clear acute intracranial abnormality identified. Clinical impression favored acute metabolic encephalopathy and post-viral vestibular process with associated dizziness and instability rather than acute cerebrovascular event. The patient also endorsed chronic near-daily headaches with excessive ibuprofen use up to approximately 1000 mg at a time, concerning for medication overuse headaches, and she was extensively counseled to avoid excessive NSAID use despite preserved renal function during admission. Fioricet was utilized as needed for headache management with improvement in symptoms. Given chronic headache burden, Neurology initiated Topamax therapy with recommendations for outpatient neurology follow-up and counseling regarding medication side effects. Ammonia level monitoring and continued neurologic checks were recommended during admission, and no seizure activity, focal neurologic deficit, hemodynamic instability, or infectious process developed. The patient’s dizziness, gait instability, and encephalopathic symptoms improved clinically, and she became medically stable for discharge home with family. She was discharged with instructions for close outpatient follow-up with neurology and primary care, continuation of supportive vestibular precautions, and return precautions for worsening confusion, persistent vomiting, focal weakness, recurrent severe dizziness, syncope, seizure-like activity, worsening headaches, or any other acute neurologic changes.


A 79-year-old female with extensive past medical history significant for chronic systolic and diastolic congestive heart failure, newly worsened cardiomyopathy with severely reduced ejection fraction, paroxysmal atrial fibrillation with rapid ventricular response, COPD with chronic hypoxic respiratory failure on home oxygen, peripheral arterial disease, prior CVA, history of extensive lower extremity DVT requiring thrombectomy, coronary artery disease, hyperlipidemia, GERD, and chronic kidney disease/possible cardiorenal syndrome presented from Life Care Center at Wells Crossing with progressive shortness of breath, diffuse abdominal pain, lower extremity edema, anasarca, and generalized weakness. Initial evaluation demonstrated atrial fibrillation with RVR with heart rates in the 110s, pulmonary edema, bilateral pleural effusions, volume overload, and acute decompensated heart failure with acute hypoxic respiratory failure. Echocardiogram during admission revealed mildly dilated left ventricle with EF approximately 30-35%, eccentric LVH, severely dilated left atrium, dilated right atrium, RV dilation with reduced RV function, RVSP approximately 45 mmHg, moderate to severe mitral regurgitation with posteriorly displaced eccentric regurgitant jet, and moderate to severe tricuspid regurgitation, representing significant decline from previously preserved EF and concerning for rate-induced cardiomyopathy secondary to atrial fibrillation with RVR. CT imaging and serial chest radiographs demonstrated pulmonary edema and bilateral pleural effusions, right greater than left. She underwent right-sided thoracentesis on 05/04/2026 with removal of approximately 700 cc fluid with subsequent symptomatic improvement. Cardiology and pulmonology followed closely throughout hospitalization. Patient underwent successful cardioversion on 05/06/2026 with temporary restoration of sinus rhythm but later reverted back into atrial fibrillation and subsequently underwent successful cardiac ablation on 05/11/2026. Medical management included aggressive IV diuresis with Lasix, rate and rhythm control with metoprolol, diltiazem, and amiodarone, fluid restriction, strict intake/output monitoring, daily weights, supplemental oxygen, bronchodilator therapy, prednisone taper, and optimization of guideline-directed medical therapy as blood pressure tolerated. Hospital course was additionally complicated by acute kidney injury felt secondary to cardiorenal syndrome with associated hyperkalemia, both of which improved with treatment and diuresis. Given severely reduced EF, cardiology recommended LifeVest placement at discharge with plans for outpatient optimization of heart failure regimen including eventual ACE/ARB/ARNI therapy as tolerated.

Hospitalization was further complicated by hematochezia and abdominal pain prompting gastroenterology evaluation. Flexible sigmoidoscopy/EGD performed on 05/15/2026 demonstrated significant ulceration and friable rectal mucosa with areas of necrosis extending approximately 15 cm from the anal verge, findings most consistent with ischemic proctitis in the setting of severe decompensated heart failure and hypotension. Endoscopic findings were not consistent with inflammatory bowel disease. GI and surgery services recommended supportive care, maintenance of adequate perfusion with MAP greater than 65, avoidance of hypotension and rectal tube placement, serial abdominal examinations, and monitoring for evidence of worsening ischemia or gangrenous bowel. Eliquis was temporarily held due to hematochezia and downtrending hemoglobin, though anticoagulation management was coordinated with cardiology given elevated thromboembolic risk from atrial fibrillation and prior thromboembolic disease. Patient additionally had constipation with fecal impaction and stool burden which resolved during admission. Over the course of hospitalization her respiratory status improved significantly with diuresis and thoracentesis, oxygen requirements stabilized near baseline, abdominal pain improved, GI bleeding stabilized, renal function improved, and hemodynamics remained stable. At time of discharge she was continued on Lasix, beta-blocker therapy, amiodarone taper followed by maintenance dosing, COPD regimen including oxygen and bronchodilators, bowel regimen, and other home medications as clinically appropriate with antihypertensive adjustments secondary to intermittent soft blood pressures. She was discharged with LifeVest, instructions for strict fluid restriction and daily weights, close outpatient follow-up with cardiology, electrophysiology, pulmonology, gastroenterology, and primary care, and return precautions for recurrent bleeding, chest pain, worsening dyspnea, palpitations, syncope, edema, abdominal pain, fever, or any other acute concerning symptoms.


A 42-year-old male with past medical history significant for super morbid obesity with BMI approximately 64, severe bilateral lower extremity lymphedema, ambulatory dysfunction/ECOG 3 functional status, severe degenerative joint disease, hypertension, obstructive sleep apnea, chronic debility, and prolonged bedbound status following prior falls presented to Orange Park Medical Center on 02/21/2026 with foul-smelling drainage, worsening skin breakdown, and multiple infected wounds involving the bilateral lower extremities and posterior right thigh. Patient reported being largely bedridden for approximately six months, dependent on his mother for care, and utilizing a bedpan for toileting. On presentation he was tachycardic and tachypneic with laboratory studies notable for leukocytosis, normocytic anemia, elevated inflammatory markers including CRP, mild azotemia, and imaging demonstrating soft tissue gas involving the right distal femoral region concerning for necrotizing soft tissue infection. He was admitted with sepsis secondary to infected right posterior thigh necrotic wound/unstageable decubitus ulcer complicated by gangrene, bilateral proximal thigh and inguinal panniculitis/intertrigo, left posterior calf wounds with cellulitis, and extensive chronic skin breakdown. Broad-spectrum intravenous antibiotic therapy was initiated with vancomycin, cefepime, and clindamycin, and infectious disease, wound care, and general surgery services were consulted. Surgical evaluation determined the patient required operative management and he subsequently underwent excisional debridement of the right posterior thigh necrotic wound with wound VAC placement on 02/22/2026 followed by additional right thigh debridement and ongoing wound management procedures during hospitalization. Wound care, nutritional supplementation, and aggressive supportive care were continued throughout admission. Hospital course was complicated by severe deconditioning, chronic lymphedema, chronic anemia, cardiomegaly with ventricular ectopy/bigeminy and intermittent trigeminy on telemetry, and newly recognized heart failure with reduced ejection fraction with echocardiogram demonstrating EF approximately 25%. Cardiology followed throughout admission with optimization of volume status and medical therapy as tolerated.

Hospitalization became further complicated by multifactorial acute kidney injury felt secondary to hypoperfusion, sepsis, nephrotoxic exposure including supratherapeutic vancomycin levels, and cardiorenal physiology. Nephrology followed closely throughout admission. Patient developed worsening renal function with oliguria, hyperkalemia, and hyperphosphatemia requiring medical management including calcium gluconate, insulin, dextrose, phosphate binders, IV fluid adjustments, and eventual initiation of hemodialysis on 02/28/2026. Renal function subsequently stabilized with creatinine plateauing in the low 3 range and dialysis was later discontinued as urine output and renal recovery improved. During prolonged hospitalization, patient was also incidentally found to have a large intra-abdominal fluid collection/cystic lesion of unclear etiology requiring IR-guided drain placement and later diagnostic laparoscopy with abdominal cyst debridement on 03/30/2026. Serial imaging demonstrated gradual decrease in size of the fluid collection and JP drainage was continued with ongoing surgical follow-up. Additional complications during admission included severe chronic edema with buried penis requiring Foley catheter placement for urinary drainage and intake/output monitoring, persistent malnutrition risk requiring vitamin and nutritional supplementation, and profound physical debility requiring multidisciplinary rehabilitation planning. Over the course of hospitalization, sepsis resolved, leukocytosis improved, wounds gradually stabilized with wound VAC therapy and serial debridements, renal function improved sufficiently to discontinue dialysis, and hemodynamics remained stable. At discharge patient remained significantly debilitated but medically improved from initial presentation. He was discharged with ongoing wound care instructions including wound VAC management, close follow-up with surgery, nephrology, cardiology, infectious disease, wound care, and primary care, continuation of diuretics and other adjusted medications as tolerated, nutritional optimization recommendations, lymphedema clinic referral, and strict return precautions for recurrent fever, worsening drainage, bleeding, chest pain, dyspnea, decreased urine output, abdominal pain, or any other acute concerning symptoms.



A 56-year-old male with past medical history significant for type 2 diabetes mellitus, chronic Guillain-Barré syndrome, prior metastatic kidney cancer currently in remission, coronary artery disease status post prior cardiac stenting, and multiple prior orthopedic and abdominal surgeries presented to Orange Park Medical Center on 05/12/2026 for evaluation of worsening right great toe discoloration and necrotic appearing diabetic foot wound. Patient reported that the lesion initially began several months prior as a callus on the plantar aspect of the foot with progressive discoloration and worsening appearance over time, eventually developing black necrotic changes involving the right great toe prompting evaluation by his primary care physician and referral to the emergency department. On presentation patient was noted to meet sepsis criteria with tachycardia and leukocytosis. Laboratory studies demonstrated elevated glucose levels with poorly controlled diabetes and imaging of the right foot revealed comminuted fracture involving the base of the first distal phalanx with intra-articular extension as well as soft tissue swelling and gas involving the great toe concerning for necrotizing diabetic foot infection and osteomyelitis, with pathologic fracture unable to be excluded. Patient was admitted for sepsis secondary to necrotizing right diabetic foot infection with osteomyelitis of the right great toe. Broad-spectrum intravenous antibiotics were initiated and infectious disease as well as podiatry services were consulted. MRI subsequently demonstrated extensive osteomyelitis involving the proximal and distal phalanx of the right great toe. Patient underwent operative intervention on 05/15/2026 consisting of right great toe amputation with incision and drainage of deep abscess and excisional debridement of ulcerated nonviable subcutaneous tissue, muscle, tendon, adipose tissue, and fascia measuring approximately 4.8 x 3.9 x 1.1 cm. Intraoperative cultures grew Staphylococcus aureus with mixed gram-positive flora and MRSA screening was positive. Source control was felt to be achieved following surgical intervention.

Following surgery, patient remained hemodynamically stable with gradual improvement in leukocytosis and clinical signs of infection. Infectious disease followed closely throughout hospitalization and antibiotic therapy was adjusted based on culture data and sensitivities. Zosyn was discontinued once cultures finalized growing Staphylococcus aureus, and patient was continued on intravenous vancomycin with plan for transition to doxycycline 100 mg orally twice daily to complete a prolonged antibiotic course totaling approximately four weeks from operative intervention pending finalized susceptibilities. Diabetes management was optimized during hospitalization with Accu-Chek monitoring, sliding scale insulin coverage, diabetic diet, and endocrinology consultation given hemoglobin A1c of 8.6 and persistent hyperglycemia. Podiatry followed postoperatively and noted stable postoperative course without acute overnight events. Patient was instructed to remain strict non-weight-bearing to the right foot, maintain surgical dressings clean, dry, and intact, keep the right lower extremity elevated as much as possible, and utilize intermittent ice behind the knee for pain and inflammation control. By discharge, sepsis had resolved, postoperative wound remained stable, and patient was tolerating treatment plan without acute complications. Patient was discharged home in stable condition with close follow-up arranged with podiatry, infectious disease, endocrinology, and primary care. He was instructed regarding strict adherence to wound care recommendations, diabetic management, completion of antibiotic therapy, smoking cessation counseling as applicable, and immediate return precautions for recurrent fever, worsening drainage, increased pain, erythema, swelling, bleeding, or any other concerning symptoms.



A 65-year-old female with past medical history significant for hypertension, hyperlipidemia, prior cerebrovascular accident on Plavix, rheumatoid arthritis, COPD with active tobacco use, and reduced functional status was transferred from Lake City to Orange Park Medical Center for higher level of care after presenting with witnessed seizure activity, altered mental status, progressive lethargy, and concern for cervical spine injury. Per husband, patient had become increasingly lethargic, largely bedbound and remaining in a recliner for approximately one week prior to presentation. Outside hospital imaging demonstrated C1-C2 subluxation and patient arrived wearing a cervical collar for stabilization. On admission patient was noted to be septic with tachycardia, marked leukocytosis, urinary tract infection, multiple skin and soft tissue infections, and extensive sacral/buttock wounds including an unstageable sacral decubitus ulcer with necrotic tissue involving the left inferior gluteal region. Initial laboratory studies were notable for leukocytosis, hypokalemia, anemia, and subsequent hyponatremia felt secondary to SIADH. Infectious disease, neurology, neurosurgery, wound care, nephrology, and general surgery services were consulted during hospitalization. Broad-spectrum intravenous antibiotics including vancomycin, cefepime, and antifungal therapy were initiated for management of sepsis secondary to polymicrobial skin and soft tissue infection, sacral decubitus ulcer, candidal superinfection involving multiple skin folds/perineum/bilateral buttocks, and urinary tract infection. Neurosurgery recommended continued cervical collar immobilization for C1-C2 subluxation with associated cervical cord compression. General surgery evaluated the patient and she subsequently underwent debridement of necrotic tissue involving the bilateral buttocks and sacral wounds on 05/02/2026. Due to severity and location of wounds with ongoing contamination risk, patient additionally underwent laparoscopic diverting colostomy creation on 05/07/2026. Wound cultures grew Candida albicans, Candida krusei, and Corynebacterium species. Hospital course was further complicated by dehydration, hypotension requiring IV fluid support and midodrine, heart failure with reduced ejection fraction, hypophosphatemia, persistent electrolyte abnormalities, anemia, hyperglycemia, and severe overall debility.

Throughout hospitalization patient remained medically complex with poor functional reserve and significant wound burden requiring multidisciplinary management. Nephrology followed for SIADH-associated hyponatremia with sodium chloride tablet supplementation and careful fluid management. Infectious disease monitored antimicrobial therapy closely with completion of vancomycin, cefepime, and antifungal treatment through 05/16/2026, after which topical miconazole therapy was continued. Despite surgical debridement and diverting colostomy, patient demonstrated ongoing challenges with wound care compliance, including intermittent refusal of dressing changes secondary to pain, and prognosis regarding wound healing and long-term recovery was discussed extensively with both patient and husband. Palliative care was involved for goals of care discussions given overall poor prognosis, severe debility, chronic neurologic impairment, extensive wounds, and multisystem medical issues. At time of discharge, patient remained hemodynamically stable with cervical collar in place, colostomy functioning appropriately, and no further acute seizure activity noted. She was discharged to skilled nursing/rehabilitation facility for continued wound care, colostomy management, physical rehabilitation, pressure offloading, cervical spine precautions, nutritional optimization, and close outpatient follow-up with primary care, neurosurgery, wound care, infectious disease, nephrology, and surgery as indicated. Patient and family were counseled extensively regarding importance of adherence with wound care recommendations, pressure injury prevention, dressing changes, medication compliance, smoking cessation, and return precautions for worsening infection, fever, altered mentation, drainage, bleeding, or any other concerning symptoms.