Patient Note (Ben)
Ben
(Patient ID 001)
| Name: Ben | Age: 20 | Admit date: one week ago | MR #: 000-001 |
| Gender Identity: Male | Race: Caucasian |
Admitting diagnosis: Infective endocarditis, L MCA |
Insurance: Medicaid |
| History of present illness: 20-year-old man admitted to ER in an unconscious state with agonal respirations, found to have endocarditis and critical aortic stenosis and L MCA aneurysm. Intubated on arrival and extubated 5 days later. Underwent AVR and NG tube placement the day after arrival. Diagnosed with septic shock and R hemiplegia. | |
| Past medical/surgical history: HIV+, substance abuse disorder, possible depression, + smoker 2 PPD. |
| Social History: Lives with father who works full time but is supportive. Has history of IV drug abuse and methamphetamine use. Has long time girlfriend and enjoys playing guitar. Father has been urging him to seek outpatient drug treatment for some time without success. | |
| Employment/work/school: Left school in 10th grade, currently unemployed. | |
| Prior level of function: Independent in ambulation unlimited community distances with no device. Independent for washing, dressing, cooking, household chores, was able to drive. Per father, able to perform financial duties but often neglected them, leaving them for father to complete. | |
| Living situation/environmental barriers: Lives in second floor of rented home with 4 steps to enter with no rail. Inside home 13 steps to living area with rail on R ascending. Once inside bedroom and bath and all living spaces are on one floor. |
Sternal precautions
PICC line
NG tube
Ground solids and nectar thick liquids
Monitor othostatic vital signs
OOB
Lopressor
Nicotine patch
Oxycodone
MRI: extensive L MCA CVA
Chest x-ray: atelectasis of bilateral lower lobes
Hematocrit=29% (2 days ago was 26), WBC 12,500, platelets 350,000.
| Result | Reference Range | Date | Date | Date | Date |
| Calcium | 8.6-10.3 mg/dL | ||||
| Chloride | 99-108 mEq/L | ||||
| Glucose | 70-100 mg/dL | ||||
| Potassium | 3.7-5.1 mEq/L | ||||
| Sodium | 134-142 mEq/L | ||||
| BUN | 6-25 mg/dL | ||||
| Creatinine | 0.7-1.3 mg/dL | ||||
| Magnesium | 1.2-1.9 mEq/L | ||||
| Total protein | 6.4-8.3 g/L | ||||
| Albumin | 3.2-4.8 g/L | ||||
| Hemoglobin | 14-17.4 g/dL | ||||
| Hematocrit | 42-52% | ||||
| WBC | 5.0-10.0 109 | ||||
| Platelets | 140-400 k/uL | ||||
| INR | 2.0-2.5 (stroke) | ||||
| T4 count |
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.