What is the appropriate inpatient management for a 65‑year‑old female nursing‑home resident with newly diagnosed HIV, chronic hepatitis C, seizure disorder on phenytoin, levetiracetam, and oxcarbazepine (possible phenytoin toxicity), sinus bradycardia with irregular rhythm, history of lung cancer with right‑upper‑lobe lobectomy, pending cataract surgery, gait instability, malnutrition, and psychosocial conflict?

Immediate Management Priorities for This Complex Nursing Home Patient

This patient requires immediate discontinuation of phenytoin, urgent HIV treatment initiation, comprehensive medication reconciliation, and transfer to a higher-acuity facility with multidisciplinary support. The constellation of phenytoin toxicity, newly diagnosed untreated HIV, chronic hepatitis C, cardiac arrhythmia, malnutrition, and psychosocial crisis demands coordinated specialist care that exceeds typical nursing home capabilities.

Urgent Phenytoin Toxicity Management

Stop phenytoin immediately and check serum phenytoin level stat. 1, 2

• The patient's presentation of being "out cold" with recent hospitalization for "too much dilantin" strongly suggests phenytoin toxicity, which manifests as confusion, altered consciousness, ataxia, and encephalopathy 1, 3
• Phenytoin has non-linear kinetics with a narrow therapeutic window; small dose increases can rapidly produce toxic levels, particularly in elderly patients and those with impaired liver function 1, 3
• Switch to levetiracetam 500-1000 mg twice daily as the primary antiepileptic, as it requires no hepatic metabolism and is safe in patients with liver disease 4
• The patient is already on levetiracetam 500 mg daily (subtherapeutic dosing) and oxcarbazepine 300 mg BID, suggesting prior attempts to transition away from phenytoin 4

Critical pitfall: Phenytoin toxicity itself can paradoxically cause seizures, especially when levels exceed 30 mcg/mL 5. Do not increase phenytoin dose if breakthrough seizures occur during toxic levels.

HIV Treatment Initiation - Highest Priority

Initiate antiretroviral therapy (ART) immediately, as delays in HIV treatment are potentially fatal. 6

• Start integrase strand transfer inhibitor (InSTI)-based regimen within 48-72 hours of HIV diagnosis confirmation 6
• Recommended regimen: Bictegravir/tenofovir alafenamide/emtricitabine (single tablet daily) or dolutegravir-based regimen, as InSTIs have minimal drug-drug interactions and do not require hepatic metabolism adjustment 6
• Avoid efavirenz and nevirapine due to significant drug interactions with antiepileptic medications 6
• Check baseline CD4 count, HIV viral load, resistance testing, hepatitis B surface antigen, and screening for opportunistic infections before starting ART 6
• Screen for tuberculosis, toxoplasmosis, and cryptococcal infection given her immunocompromised status 6

The patient's shock at learning her HIV diagnosis indicates complete failure of the healthcare system - HIV was documented on her nursing home facesheet but never communicated or treated, representing potential medical negligence 6.

Hepatitis C Management Considerations

Defer hepatitis C treatment until HIV is controlled and patient is stabilized, but plan for future direct-acting antiviral therapy. 6

• Chronic hepatitis C significantly increases mortality risk in HIV coinfection and accelerates liver disease progression 6
• Modern interferon-free regimens are highly effective but require multidisciplinary team coordination including pharmacy review for drug-drug interactions with ART and antiepileptics 6
• Counsel patient to abstain from alcohol completely, as her cannabis use suggests potential substance use issues that impair treatment adherence 6
• Patients with ongoing substance use require additional support services and harm reduction programs during antiviral therapy 6

Cardiac Management

Obtain 12-lead ECG immediately and cardiology consultation for sinus bradycardia with irregular rhythm. 6

• Pulse of 55 with irregular rhythm raises concern for sick sinus syndrome, atrial fibrillation with slow ventricular response, or high-grade AV block 6
• Phenytoin toxicity can exacerbate cardiac conduction abnormalities 1
• Rule out medication-induced bradycardia from drug interactions between phenytoin and other medications 1
• Consider telemetry monitoring given her history of cardiac arrhythmias and risk of sudden cardiac death 6

Nutritional and Metabolic Support

Initiate aggressive nutritional supplementation and correct protein-calorie malnutrition. 6

• Mild protein-calorie malnutrition increases infection risk, impairs wound healing, and worsens outcomes in HIV and hepatitis C 6
• Check albumin, prealbumin, vitamin D, calcium, magnesium, and phosphate levels 7, 1
• Phenytoin induces CYP450 enzymes, increasing vitamin D metabolism and causing hypocalcemia, hypophosphatemia, and osteomalacia risk 1
• Malnutrition impairs phenytoin metabolism and increases toxicity risk 1, 3

Seizure Disorder Optimization

Consolidate to levetiracetam monotherapy and discontinue polypharmacy. 4

• Current regimen of phenytoin + levetiracetam + oxcarbazepine represents excessive polypharmacy with increased adverse effect risk 4
• Target levetiracetam dose: 1000-1500 mg twice daily for adequate seizure control 4
• Levetiracetam is the optimal choice given her hepatic disease (hepatitis C), avoiding hepatotoxic antiepileptics like phenytoin, valproic acid, and felbamate 4
• Monitor for levetiracetam-associated behavioral changes, though less concerning than phenytoin encephalopathy 4

Psychosocial and Care Coordination

Arrange immediate social work consultation and patient advocacy services for the facility conflict and potential litigation. 6

• The verbal altercation with staff and patient's desire to pursue litigation for failure to treat HIV requires formal investigation 6
• Transfer to a different skilled nursing facility is medically and ethically appropriate given the breakdown in therapeutic relationship and documented failure to communicate HIV diagnosis 6
• Multidisciplinary team must include case management, social work, psychiatric support, and peer support services for HIV and substance use 6
• Screen for depression using validated instruments, as depression is highly prevalent in HIV patients and impairs treatment adherence 6

Vision and Functional Status

Ophthalmology referral for cataract surgery planning once medically stabilized. 6

• Blindness in right eye (category 5) and low vision in left eye (category 2) with cataracts severely impairs quality of life and increases fall risk 6
• Cataract removal in the functional left eye could significantly improve independence and safety 6
• Defer surgery until HIV viral suppression achieved and CD4 count improved to reduce perioperative infection risk 6

Fall Prevention and Gait Instability

Implement comprehensive fall prevention protocol immediately. 6

• History of falls, gait instability, visual impairment, and phenytoin toxicity create extremely high fall risk 6
• Physical therapy evaluation for assistive devices and environmental modifications 6
• Review all medications for those increasing fall risk (phenytoin, oxcarbazepine, celecoxib) 1
• Ensure adequate lighting, remove tripping hazards, and provide bedside commode 6

Monitoring and Follow-Up Schedule

Establish intensive monitoring protocol for the first 4-6 weeks:

• Week 1: Daily phenytoin levels until undetectable, daily neurological assessments, HIV viral load and CD4 count, comprehensive metabolic panel, ECG monitoring 6, 1
• Week 2-4: Weekly HIV viral load to confirm ART response, weekly metabolic panels, seizure diary, medication adherence assessment 6
• Week 4-6: Repeat HIV viral load (should show >1 log reduction), CD4 count, hepatitis C viral load, nutritional markers 6
• Ongoing: Monthly HIV viral load until undetectable, then every 3-6 months; quarterly STI screening; biannual ophthalmology follow-up 6

Critical Drug-Drug Interactions to Avoid

Phenytoin interacts dangerously with multiple medications this patient may encounter: 1, 8

• Never combine phenytoin with isoniazid (if TB diagnosed) - isoniazid blocks CYP2C19, preventing phenytoin metabolism and causing catastrophic toxicity 8
• Avoid azole antifungals, macrolide antibiotics, and fluoroquinolones which increase phenytoin levels 1
• Many antiretrovirals interact with phenytoin; InSTI-based regimens have minimal interactions 6
• Pharmacy consultation mandatory before adding any new medication 6

Facility-Level Recommendations

This patient requires transfer to a facility with:

• On-site infectious disease specialists experienced in HIV/hepatitis C coinfection management 6
• Cardiology consultation availability for arrhythmia management 6
• Neurology consultation for seizure disorder optimization 4
• Robust pharmacy services for complex drug interaction monitoring 6
• Social work and psychiatric services for substance use and mental health support 6
• Physical and occupational therapy for fall prevention and functional optimization 6

The current facility has demonstrated inability to provide adequate care through failure to recognize and treat documented HIV diagnosis, representing a sentinel safety event requiring reporting and investigation 6.