++
+++
History of Present Illness
++
US is a 41-year-old Caucasian male who presented to the emergency department (ED) 24 hours ago via EMS after suffering a motorcycle accident. According to bystanders, US hit a patch of loose gravel and was ejected from the motorcycle, landing on the pavement approximately 10 feet away. Upon presentation to the ED, US was found to have a Glasgow Coma Score (GCS) = 8 and a negative focused assessment with sonography in trauma (FAST) exam. Following a trip to the operating room for an open reduction, internal fixation (ORIF) of the left knee, US was transferred to the intensive care unit (ICU), intubated and sedated.
++
Hypertension, hyperlipidemia
++
ORIF of left knee 12 hours ago
++
++
++
Annual influenza vaccination, otherwise unknown at present time
++
++
++
Propofol continuous infusion, currently at 150 mcg/kg/min
Hydromorphone continuous infusion, currently at 0.7 mg/h
Hydromorphone 0.2 mg IV bolus PRN breakthrough pain—no doses received
Cefazolin 1 gr IV q8h × 6 doses
Gentamicin 5 mg/kg as a single dose—received in ED
Heparin 5000 SQ q8h
Lorazepam 1 mg IV q2h PRN agitation—no doses received
Low level sliding scale insulin protocol—no doses received
Electrolyte replacement protocol—no doses received
Famotidine 20 mg PO bid
++
Tmax since admission 99.5°F, BP 108/92 mmHg, HR 86 bpm; RR 18 breaths/min; Ht: 180 cm, Wt: 112 kg
++
Intubated and sedated male patient.
++
PERRLA; otherwise deferred.
++
PRCV ventilation setting.
++
++
Soft, nondistended, hypoactive bowel sounds.
++
Foley catheter visualized, otherwise deferred.
++
GCS = 8 on admission, no changes appreciated. RASS = +1, CPOT = 2, CAM-ICU = negative.
++
Significant abrasions appreciated on all four extremities; fresh incision, without purulence or erythema, visualized under dressing on left knee.