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PATIENT PRESENTATION

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.

Past Medical History

Hypertension

Type 2 diabetes mellitus

Family History

Mother died from a myocardial infarction at age 84. Father is still living in nursing home, has past history of prostate cancer.

Social History

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.

Current Medications

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

Allergies

NKDA

Home Medications

Lisinopril/hydrochlorothiazide 20/12.5 mg PO daily

Metformin 1000 mg PO BID

No recent antibiotic use within the past 6 months

Vital Signs

Temp 101.3°F, BP 110/72 mm Hg, HR 80 to 90 bpm, RR 21 breaths per minute, SpO2 92% on mechanical ventilation

Ht 6′1″ Wt 98 kg

General

Intubated, no acute distress

HEENT

Normocephalic, atraumatic, EOMI, PERRLA, MMM, no adenopathy

Cardiovascular

No m/r/g, normal S1/S2

Pulmonary

Crackles in the right posterior base with dullness: left lung clear

Abdomen

Soft, non-tender, non-distended with positive bowel sounds

Genitourinary

Urinary (Foley) catheter is in place

Extremities

LLE in ace wrap and post-op bandages, LUE in post-op bandages

Neurology

Alert and oriented × 2 upon admission (person and place, not date)

Laboratory Findings

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