Patient History: Painful Urination and Tachycardia

• Cordie Payton's information was collected on April 29, 2025.
• The patient's chief complaints include painful urination and tachycardia.

History of Present Illness (HPI)

• An 80-year-old male with a history of chronic smoking was admitted from an outside facility.
• The patient presented to the Emergency Department with new-onset atrial fibrillation with a rapid ventricular response.
• Prior to arrival, diltiazem drip was administered.
• The patient reported urinary retention, painful urination, dribbling, and difficulty fully emptying his bladder over the past several days.

Past Medical History (PMH)

• Abdominal Aortic Aneurysm
• Anxiety
• Depression
• Atherosclerosis Coronary Artery of Native Heart without Angina Pectoris
• Carotid Artery Occlusion
• COPD with Acute Bronchitis
• Hyperlipidemia
• Hypertension

Past Surgical History (PSH)

• Abdominal Aortic Aneurysm Repair with Endoluminal Graft
• Cardiac Catheterization with Stent Placement
• Colonoscopy
• Coronary Angioplasty with Stent Placement
• Hybrid Right Femoral Artery Stents with Shockwave – Bilateral -2020
• Vascular Surgery

Allergies

• Codeine
• Morphine

Family History (FH)

• Father: Stroke
• Sibling: Sister - Cancer

Social History (SH)

• Tobacco - 1 pack a day

Immunizations (IMZ)

• Influenza [Sept 2022]
• PCV13 [insert year admin]
• PPSV23 [insert year admin]
• PCV-15 [insert year admin]
• PCV20 [insert year admin]
• Tdap/Td [insert year admin]
• RZV [insert year admin]
• VAR [insert month/year admin]
• SARS-CoV-2 [insert product, month/year, month/year]

Home Medications

• Albuterol HFA (ProAir) 90 mcg inhaler involves inhaling 2 puffs every 6 hours if needed for wheezing or shortness of breath.
• ALPRAZolam (Xanax) 0.5mg involves taking one 0.5 mg tablet by mouth if needed in the morning and bedtime for anxiety.
• Apixaban (Eliquis) 5mg involves taking one 5mg tablet by mouth 2 times a day.
• Aspirin 81 mg EC involves taking one 81mg tablet by mouth every other day.
• Clopidogrel (Plavix) 75mg involves taking one 75mg tablet by mouth daily.
• Enalapri (Vasotec) 20mg involves taking one 20mg tablet by mouth 2 times a day.
• Ipratropium-Albuterol (Duo-Neb) 0.5-2.5mh/3ml nebulizer solution involves taking 3 mL by nebulization every 8 hours if needed for wheezing or shortness of breath.
• Escitalopram (Lexapro) 10mg involves taking one 10mg tablet by mouth daily.
• Finasteride (Proscar) 5 mg involves taking one 5mg tablet by mouth in the morning.
• Gabapentin (Neurontin) 300mg involves taking one 300mg capsule by mouth in the morning, at noon, and at bedtime.
• Tamsulosin (Flomax)0.4 mg involves taking one 0.4 mg capsule by mouth daily.
• Metoprolol Succinate (Toprol XL) 25 mg involves taking one 25mg tablet by mouth in the morning.
• Hydrocodone-Acetaminophen 10-325 mg involves taking one tablet (10-325) by mouth if needed in the morning, at noon, and at bedtime for moderate pain.

Physical Exam on Admission

• General: Normal
• Psychiatric: Normal
• Neurological: Normal
• HEENT: Normal
• Cardiovascular: Tachycardia and Rhythm irregular
• Respiratory: Wheezing
• Musculoskeletal: Normal
• Gastrointestinal: Normal
• Genitourinary: Dysuria and Flank Pain
• Extremities: Normal
• Skin: Normal

Vital Signs - Day 1

• Temperature: 36.7 °C
• SBP: 92 mmHg
• DBP: 58 mmHg
• Respiratory Rate: 18 bpm
• O2 saturation: 96%
• Height: 5'11"
• Weight: 84 kg
• BMI: 25.83 kg/m²

Inpatient Medications: Scheduled Medications

• Apixaban (Eliquis) 5 mg by mouth twice daily for Stroke prevention (AFib)
• Diltiazem CD (Cardizem CD) 120 mg by mouth once daily for Rate control (AFib)
• Enalapril (Vasotec) 20 mg by mouth twice daily for Hypertension / CAD
• Metoprolol succinate (Toprol XL) 25 mg tablet by mouth once daily for Heart rate / BP control
• Tamsulosin (Flomax) 0.4 mg capsule by mouth once daily for BPH / urinary retention
• Pravastatin (Pravachol) 80 mg tablet by mouth once daily for Hyperlipidemia / ASCVD
• Pantoprazole (Protonix) 40 mg tablet by mouth once daily for GI protection
• Clopidogrel (Plavix) 75 mg tablet by mouth once daily for Post-PCI / CAD
• Aspirin EC 81 mg tablet by mouth every other day for Secondary ASCVD prevention
• Escitalopram (Lexapro) 10 mg tablet by mouth once daily for Anxiety
• Gabapentin (Neurontin) 300 mg capsule by mouth three times daily for Neuropathic pain
• Finasteride (Proscar) 5 mg tablet by mouth once daily for BPH
• Heparin 5000 units/ 5000 units subcutaneously three times daily for DVT prophylaxis

Inpatient Medications: PRN Medications

• ALPRAZolam (Xanax) Take 0.5mg by mouth daily PRN for Anxiety
• Hydrocodone-Acetaminophen (Norco) 5-325 mg by mouth PRN for Moderate pain
• Hydrocodone-Acetaminophen (Norco) 10-325 mg by mouth 3 times PRN for Moderate pain
• Ipratropium-Albuterol (Duo-Neb) 0.5/2.5 mg per 3 mL via nebulizer q8h PRN for Wheezing/COPD
• Levalbuterol (Xopenex) 1.25 mg/3mL every 6 hours PRN for Wheezing
• Morphine Injection 2mg intravenous every 4 hours PRN for Severe Pain
• Nicotine Lozenges 2mg every hour PRN for Smoking Cessation
• Iohexol 350mg/mL injection 80-1125ml intravenous once in imaging for Imaging
• Perflutren Lipid microsphere In Sodium Chloride 0.9% 10mL IV syringe 1-10mL intravenous once in imaging for Imaging

Inpatient Medications: Continuous Infusions

• Diltiazem 100mg in 0.9%NaCL (1mg/ml) 100mL given 5-15mg/hr for Atrial Flutter with RVR
• Sodium Chloride 0.9% infusion 100 ml/hr intravenously continuously

Heparin Standard Dose SS (DVT, PE)

• aPTT < 47: Increase dose by 4 units/kg/hr (no max rate) and bolus 80 units/kg (MAX bolus 7500 units).
• aPTT 48-63: Increase dose by 2 units/kg/hr (no max rate) and bolus 40 units/kg (MAX bolus 5000 units).
• aPTT 64-92: No change.
• aPTT 93-115: Decrease dose by 1 unit/kg/hr.
• aPTT 116-135: Hold infusion for 1 hour. Decrease dose by 2 units/kg/hr.
• aPTT 136-155: Hold infusion for 2 hours. Decrease dose by 3 units/kg/hr.
• aPTT > 156: Hold infusion for 3 hours then obtain aPTT. If aPTT < 92, resume heparin at dose decreased by 4 units/kg/hr. If aPTT 93-155, hold heparin for 1 hour, then resume at a dose reduced by 5 units/kg/hr.

Inpatient Laboratory Findings

• Sodium: Day 1: 138 mmol/L, Day 2: 139 mmol/L (Reference: 137-145 mmol/L)
• Potassium: Day 1: 4 mmol/L, Day 2: 4.3 mmol/L (Reference: 3.5-5.3 mmol/L)
• Chloride: Day 1: 109-H mmol/L, Day 2: 104 mmol/L (Reference: 98-107 mmol/L)
• Carbon Dioxide: Day 1: 23 mmol/L, Day 2: 28 mmol/L (Reference: 22-30 mmol/L)
• Anion Gap: Day 1: 6.0-L mmol/L, Day 2: 7.0 mmol/L (Reference: 7-16 mmol/L)
• Glucose, serum: 120 mg/dL (Reference: 75-110 mg/dL)
• Bedside glucose: (Reference: 70-110 mg/dL)
• Hgb A1c: 5.8 % (Reference: 4.0-6.0%)
• Calcium: Day 1: 9.4 mg/dL, Day 2: 9.9 mg/dL (Reference: 8.4-10.2 mg/dL)
• Ionized Calcium: (Reference: 4.5-5.3 mg/dL)
• Magnesium: Day 1: 2.0 mg/dL (Reference: 1.6-2.4 mg/dL)
• Phosphorus: (Reference: 2.5-4.5 mg/dL)
• BUN: Day 1: 10 mg/dL, Day 2: 13 mg/dL (Reference: 9-20 mg/dL)
• SCr: Day 1: 0.79 mg/dL, Day 2: 0.64-L mg/dL (Reference: 0.66-1.25 mg/dL)
• BUN/SCr ratio: 12.66 Day 2: 20.31
• Estimated GFR: Day 1: 90, Day 2: 96 (Reference: > 60 ml/min/1.73m²)
• Estimated CrCl: (Reference: > 60 ml/min)
• Serum Osmolality: (Reference: 280-300 mOsm/kg)
• Lactic Acid: (Reference: 0.7-2.1 mmol/L)
• Alkaline Phosphatase: Day 1: 45 units/L (Reference: 36-126 units/L)
• SGPT (ALT): Day 1: 15 units/L (Reference: < 34 units/L)
• SGOT (AST): Day 1: 16 units/L (Reference: 14-36 units/L)
• LDH: (Reference: 120-246 units/L)
• CPK: (Reference: 55-170 units/L)
• Total bilirubin: 0.1 mg/dL (Reference: 0.2-1.3 mg/dL)
• Direct bilirubin: (Reference: 0.0-0.3 mg/dL)
• Ammonia: (Reference: 9-30 mcmol/L)
• Total protein: Day 1: 6.1-L g/dL (Reference: 6.3-8.2 g/dL)
• Albumin: Day 1: 3.7 g/dL (Reference: 3.5-4.8 g/dL)
• Cholesterol: Day 1: 108 mg/dL (Reference: <200 mg/dL)
• HDL: Day 1: 44 mg/dL (Reference: >40 mg/dL)
• LDL: Day 1: 50 mg/dL (Reference: <100 mg/dL)
• Triglyceride: Day 1: 89 mg/dL (Reference: <150 mg/dL)
• PTH, Intact: (Reference: 9.0-65.2 pg/mL)
• Vitamin D-25 (OH): (Reference: >30 ng/mL)
• Amylase: (Reference: 30-110 units/L)
• Lipase: (Reference: 23-300 units/L)
• WBC: Day 1: 8.4 cells/nL (Reference: 4.8-11.0 cells/nL)
• RBC count: Day 1: 4.04-L cells/pL (Reference: 4.2-5.4 cells/pL)
• Hemoglobin: Day 1: 12.0-L g/dL (Reference: 12.0-16. g/dL)
• Hematocrit: 37.7 % (Reference: 36-46%)
• Platelets: Day 1: 51-H cells/nL (Reference: 140-440 cells/nL)
• Mean PLT volume: Day 1: 9.4 fL (Reference: 8.3-11.9 fL)
• MCV: Day 1: 93 fL (Reference: 84-100 fL)
• RBC Distr Width: Day 1: 31.8 fL (Reference: 35-48 fL)
• Mean Cell Hgb: Day 1: 29.7 pg (Reference: 27-31 pg)
• Seg Neutrophils: (Reference: 50-70%)
• Neutrophils Relative: Day 1: 63 (Reference: 0-15%)
• Neutrophils Absolute: Day 1: 5.3
• Im. Granulocytes: Day 1: 0 (Reference: 0-1%)
• Lymphocytes Relative: Day 1: 24 (Reference: 20-40%)
• Lymphocytes: Day 1: 2.0
• Monocytes Relative: Day 1: 9 (Reference: 1-10%)
• Monocytes Absolute: Day 1: 0.7
• Eosinophils Relative: Day 1: 3 (Reference: 0-5%)
• Eosinophils Absolute: Day 1: 0.2
• Basophils Relative: Day 1: 1(Reference: 0-1%)
• Basophils Absolute: Day 1: 0.1
• Microcytosis: Absent
• Hypochromia: Absent
• Macrocytosis: Absent
• Reticulocyte Count: Day 1: 0 (Reference: 0.5-1.5%)
• Absolute Retic
• Iron: (Reference: 49-181 mcg/dL)
• Iron Binding Cap: (Reference: 261-462 mcg/dL)
• Iron Saturation: (Reference: 11-40%)
• Haptoglobin: (Reference: 33-171 mg/dL)
• Ferritin: (Reference: 18-464 ng/mL)
• Prothrombin: (Reference: 12.0-14.6 sec)
• INR: (Reference: 0.9-1.2)
• PTT: (Reference: 25-36 sec)
• Fibrinogen: (Reference: 200-424 mg/dL)
• D-dimer: (Reference: 0.27-0.45 mcg/mL FEU)
• Anti-Thrombin III: (Reference: 82-127%)
• TEG-R: (Reference: 5.0-10.0 min)
• TEG-K: (Reference: 1.0-3.0 min)
• TEG-Angle: (Reference: 53-72 deg)
• TEG-MA: (Reference: 50-70 mm)
• TEG Interpret
• Fecal Occult Blood: NEG
• Vancomycin, trough: (Reference: 10-20 mcg/mL)
• Vitamin B12: (Reference: 239-931 pg/mL)
• Folate, Serum: (Reference: 2.76-20 ng/mL)
• Prealbumin: (Reference: 17.6-36.0 mg/dL)
• CRP: (Reference: 0.0-0.9 mg/dL)
• Free Thyroxine: 1.15 (Reference: 0.78-2.19 ng/dL)
• TSH: Day 1: 0.48, Day 2: 0.130 (Reference: 0.465-4.680 mIU/mL)
• Troponin: (Reference: 0.0-0.03 ng/mL)
• NT-proBNP: (Reference: <300 pg/mL)
• Procalcitonin: (Reference: ≤ 0.15 ng/mL)
• (1-3)-B-D-Glucan: (Reference: <60 pg/mL)
• CPK
• Prealbumin

Procedures/Diagnostics/Imaging

• Abdomen and Pelvis CT Scan with IV Contrast on Day 1:
  • The liver and gallbladder are unremarkable, with no biliary ductal dilatation.
  • The spleen is normal and configured.
  • The pancreas, adrenal glands, and kidneys demonstrated unremarkable contrasted appearance.
  • Subcentimeter cortical cyst upper pole left kidney was noted.
  • Cervical vertebral bladder wall thickening and small trabecular were noted, along with perivesical stranding.
  • Mild prostatomegaly was observed.
  • Scattered Diverticulosis along the descending and sigmoid colon.
  • Advanced scatter calcified atherosclerotic disease throughout the aorta and branch vessels.
  • Fusiform aneurysmal dilatation of the infrarenal abdominal aorta, measuring up to 3.8 cm in diameter, with moderate mural thrombus.
  • A thrombosed exophytic aneurysm along the distal right common iliac, measuring up to 2.1 cm AP dimension.
• CTA Chest PE Protocol on Day 1: No pulmonary embolism identified.
• XR Chest 1 View on Day 1: Bilateral pleural effusions without evidence of pulmonary infiltrate, consolidation, or acute infectious process, likely secondary to volume overload or chronic cardiopulmonary changes associated with underlying coronary artery disease and COPD.
• Transthoracic Echo (TTE) on Day 1:
  • The Left Ventricle is grossly normal sized, with an estimated ejection fraction of 50-55%.
  • The Right Ventricle is mildly dilated.
  • The Mitral Valve leaflets are mildly thickened/ Calcified.
  • The Tricuspid Valve appears grossly normal, with trace tricuspid regurgitation.
  • The aortic valve is grossly normal.
  • The aorta root is of normal size.
  • The inferior vena cava appeared normal and decreased > 50% with respiration (RAP 5-10mg ).
• EKG on Day 1: HR-70bpm- Atrial Flutter with predominant 4:1 AV Block--- Abnormal, RR-861 ms, Minimal ST elevation, anterior leads, QRSD 103MS, QT 442 ms, QTc- 476 ms, QRS 86 deg, T- 67 deg
• Urinalysis, Day 1:
  • Color: Red, Appearance: Clear, pH-6.0
  • Glucose NEG, Ketone NEG, Bilirubin NEG
  • Nitrite NEG, Urobilinogen- 0.2, Sp gravity -1.019
  • WBC-21.0, RBC-687, Epithelial cells NEG
  • Protein POS, Blood POS, Leukocyte -Moderate, Bacteria- Negative
  • Hyaline Cast, Urine C&S Choose an item.
• UDS, Day 1:
  • Amphetamine NEG, Methamphetamine NEG, Barbiturate NEG
  • Cocaine NEG, Opiate POS, BZD POS
  • Codeine NEG, TCA NEG, Cannabinoid NEG
  • PCP NEG, Methadone NEG, Oxycodone POS

Nutrition/Diet

• Day 1: NPO, Clear Liquid Diet, Cardiac Diet

Hospital Course

• The patient was admitted for management of new diagnosed atrial fibrillation with rapid ventricular response, characterized by a heart rate of 141 bpm and blood pressure of 92/58 mmHg.
• EKG demonstrated 2nd degree AV block with a prolonged QTc of 476 ms.
• Providers initiated IV diltiazem and later transitioned the patient to oral diltiazem 120 mg daily.
• CTA chest ruled out pulmonary embolism.
• The chest X-ray showed bilateral pleural effusions without evidence of infection.
• A transthoracic echocardiogram (TTE) demonstrated a preserved left ventricular ejection fraction (LVEF) of 50–55%, mild right ventricular dilation, and trace tricuspid regurgitation.
• Day 2: The patient remained hemodynamically stable with adequate Foley output and controlled heart rate.
• The patient was tolerating oral medications and respiratory symptoms were well-managed with nebulized bronchodilators.
• No new complications were noted and the patient was deemed stable for discharge.
• Follow-ups were arranged with cardiology, urology, and primary care.

Assess, Plan, Implement, Follow-Up

Atrial Fibrillation with Rapid Ventricular Response (RVR) [ACC/AHA 2023 AFib guidelines]

• Assessment:
  • An 80-year-old male admitted with new-onset atrial fibrillation with RVR, evidenced by HR 141 bpm and BP 92/58 mmHg.
  • EKG demonstrated atrial flutter with predominant 4:1 AV conduction block.
  • Prolonged QTc.
  • TTE showed preserved LVEF (50-55%), mild RV dilation, and trace tricuspid regurgitation without thrombus.
  • Normal Potassium 4.0mmol/L, magnesium 2.0mg/dL, stable renal function Scr- 0.79mg/dL on labs.
  • IV Diltiazem was administered to manage the heart rate.
  • Successful transition to oral Diltiazem CD 120 mg PO daily.
  • A CHA2DS2-VASc score of 4, indicating an elevated thromboembolic risk.
  • A HAS-BLED score of 2, indicating moderate risk, but anticoagulation benefits outweigh risks
• Current Inpatient medications:
  • Diltiazem CD 120 mg PO daily
  • Apixaban 5 mg PO twice daily
  • Metoprolol Succinate 25 mg PO daily
  • Heparin 5000 units subcutaneously TID
• Current Outpatient medications:
  • Apixaban 5 mg PO twice daily
  • Metoprolol Succinate 25 mg PO daily
  • Enalapril 20 mg PO twice daily
  • Aspirin EC 81 mg PO every other day
• Plan:
  • Continue oral diltiazem 120 mg daily for rate control <110 bpm at rest.
  • Continue apixaban 5 mg BID for long-term stroke prevention.
  • Discontinue Enalapril 20 mg PO twice daily due to hypotension risk.
  • Recheck electrolytes (especially K+, Mg2+) to prevent recurrence of arrhythmia.
  • Educate on bleeding signs and need for strict adherence
• Follow-Up: Cardiology appointment within 1-2 weeks post-discharge

Urinary Retention due to Benign Prostatic Hyperplasia (BPH) [American Urological Association (AUA) Guidelines on BPH-2023]

• Assessment:
  • Painful urination and incomplete bladder emptying were reported.
  • Physical exam noted genitourinary tenderness (dysuria, flank pain).
  • CT imaging revealed mild prostate enlargement, bladder wall thickening, and surrounding soft tissue inflammation.
  • Urinalysis revealed significant red blood cells, moderate white blood cells, positive for blood and protein but negative nitrites.
  • Urine culture was negative for infection.
• Current Inpatient medications:
  • Tamsulosin 0.4 mg PO once daily
  • Finasteride 5 mg PO daily
• Current Outpatient medications:
  • Tamsulosin 0.4 mg PO once daily
  • Finasteride 5 mg PO daily
• Plan:
  • Continue Tamsulosin 0.4 mg daily.
  • Continue Finasteride 5 mg daily.
  • Monitor for improvement in voiding and blood pressure.
• Follow-Up: Urology referral within 4–6 weeks

Disease State Management

Coronary Artery Disease (CAD) ACC/AHA 2022 Guideline for the Management of Patients with Chronic Coronary Disease

• Current Regimen:
  • Metoprolol succinate 25 mg PO daily
  • Clopidogrel 75 mg PO daily
  • Aspirin EC 81 mg PO every other day
  • Pravastatin 80 mg PO daily
• Assessment:
  • Patient history includes CAD with prior PCI and stent placement.
  • No anginal symptoms were reported during admission.
  • TTE revealed a preserved left ventricular ejection fraction (50-55%) and no evidence of significant valvular dysfunction apart from the mild mitral valve leaflets thickening/calcification.
  • history of hyperlipidemia, hypertension, chronic tobacco use, abdominal aortic aneurysm-all of which contribute to high ASCVD risk.
• Plan:
  • Continue current regimen
    • Metoprolol succinate 25 mg PO daily
    • Clopidogrel 75 mg PO daily
    • Aspirin EC 81 mg PO every other day
    • Pravastatin 80 mg PO daily
  • Monitor Blood pressure
  • Monitor for side effects
  • Encourage lifestyle changes

Vaccinations

• Influenza- Annual (high-dose ≥65)
• PCV20 or PCV15 + PPSV23
• Tdap
• Shingrix (Zoster)
• COVID-19 Booster

RSV (Arexvy/Abrysvo

Medication Therapy Management Checklist:

• Medications with no indication
• Indications with no medication
• Drug-Disease interaction:
  • Alprazolam (Xanax): Benzodiazepines may worsen fall risk, cognitive impairment, and respiratory depression in elderly patients with COPD and are not preferred for anxiety in older adults.
  • Gabapentin (Neurontin): CNS depression risk increases in elderly and may interact with opioid use (Norco), caution should be taken due to sedation and fall risk.
• Duplicate therapy
• Medication Antagonism:
  • Aspirin + Clopidogrel long-term (if post-PCI >1 year and no ACS): Dual antiplatelet therapy (DAPT) may not provide benefit and increases bleeding risk when used beyond recommended duration unless clinically justified.
• Medications with overlapping toxicities:
  • Gabapentin + Alprazolam + Norco (hydrocodone/acetaminophen): High risk for sedation, CNS depression, falls, and respiratory compromise in older adults and should avoid combining unless necessary and use lowest effective doses.
• Adherence/technique optimization issues:
  • Inhaler technique - Patient on Albuterol HFA and Duo-Neb.
  • Complex regimen – Multiple daily meds
• Med Access/Affordability issues