Medicine Patient

Here is how I would present one of my patients from today.

48 year old hispanic male presents with a history of a recent MVA (motor vehicle accident) resulting in a spinal injury causing quadriplegia. The patient is in respiratory failure and ventilator dependent. The patient also has a sacral decubitus that was being managed with a wound vac at the nursing home. He also suffers. from depression The patient presents with a fever of 40.1 degrees of unknown origin possibly secondary to pneumonia or UTI.

5 days ago the patient began spiking fevers at the nursing home where he lives. The fever was refractory to acetaminophen so he presented to the emergency department. Chest Xray showed evidence of pleural effusion bilaterally, right side > left. Urine was cloudy with occult blood, traces of protein and leukocyte positive. Urine culture showed subclinical pseudomonas aeruginosa susceptible to tobramycin. 

On physical exam the patients lungs had anterior coarse rhonchi bilaterally more prominent on the right side. The sacral decubitus does not appear to be infected and shows granulation tissue and signs of healing. 

Patient was started on imipenum + vancomycin for pneumonia and IV tobramycin for UTI. We will continue to monitor the patient. We have sent for blood and sputum cultures. We are continuing his lexapro for depression and will have wound control look at his sacral decubitus and possible continue the wound vac

This is a very abridged example of a presentation I may give on rounds. This is a patient that I admitted today and I am currently managing. Most likely this patient has a UTI and or pneumonia which is causing the fever. Given his comorbidities this patient will be managed in the hospital until we can get him afebrile and rid him of any infection. He is actually a good example of the type of patients that I have been managing. 

This case is sad because this guy was a normal healthy man in February until he was hit by a drunk driver which left him a quadriplegic. His wife and family have basically abandoned him in a nursing home. He is mentally aware and just trapped in his broken body. He is severely depressed and miserable. He is just waiting to die.