History of Present Illness
RW is a 67-year-old man who was transported to Acute Care Medical Center (ACMC) after being struck by a car while crossing First Avenue on foot. He has been hospitalized at ACMC for 6 days and is in the trauma ICU due to several fractures sustained in the motor vehicle accident. The patient has been intubated and on mechanical ventilation since admission 6 days ago. During ICU rounds the next morning, the nurse notes he has had increased, yellow/green secretions overnight.
Mother died from a myocardial infarction at age 84. Father is still living in nursing home, has past history of prostate cancer.
The patient is an engineering professor at the State University. He is married and lives at home with his wife. He has 2 college-age kids attending college outside of the metro area. As per his wife, he has not traveled outside the local area for the past 6 months, but he traveled to Germany about a year ago. There are no pets in the home. He drinks 2 to 3 beers per week.
Sodium chloride 0.9% (NS) @ 150 mL/hr
Heparin 5000 units subcutaneously q8 h
Insulin infusion titrated to maintain BG 80-110
Fentanyl intravenous infusion at 25 mcg/hr
Dexmedetomidine intravenous infusion titrated to RASS 0 to –2
Lisinopril/hydrochlorothiazide 20/12.5 mg PO daily
No recent antibiotic use within the past 6 months
Temp 101.3°F, BP 110/72 mm Hg, HR 80 to 90 bpm, RR 21 breaths per minute, SpO2 92% on mechanical ventilation
Intubated, no acute distress
Normocephalic, atraumatic, EOMI, PERRLA, MMM, no adenopathy
Crackles in the right posterior base with dullness: left lung clear
Soft, non-tender, non-distended with positive bowel sounds
Urinary (Foley) catheter is in place
LLE in ace wrap and post-op bandages, LUE in post-op bandages
Alert and oriented × 2 upon admission (person and place, not date)