This is a 80 year old female who presents on 4/17 as a P2 after ground level fall.
She has a history of IDDM and HTN.
Trauma bay course remarkable for right chest wall pain and headache.

Injuries (by system):
Head: SAH
Spine: None
Chest: right 3-5 rib
MSK: pubic rami fx

Consults: ortho, Neursurgery

Neuro
GCS:

# Sedation
gtt: none
sch: none
prns: melatonin qhs

# Pain
gtt: none
sch: tylenol 650, gabapentin 100 TID, lidopatches
prns: oxy5/10 q4h, dilaudid 1q2h

# SAH
Neurosurgery following
no shift
6h head ct stable
hold chemo ppx
fu 24 hr head ct

Cardiovascular
MAP: 80s
HR: 80s
Pressors: none
Trops: neg x3
EKG: age indeterminate infarct
ECHO: not indicated

# Hx of HTN
holding home antihypertensives

Respiratory
Vent settings: 3L NC
ABG: 7.41/40/100//24/-0.2
CXR: slightly congested

# Right 3-5 rib fx
No evidence of ptx, no chest tube
pain control
pulmonary toilet

GI/Nutrition
Diet: Regular
NGT/OGT: none
BM: x1
Bowel reg: PEG BID

Renal
UOP: 50/h
Foley: yes
BMP: 145/4/100/24/10/0.5
Mg/Ph: 2/3
Fluid Status:
IVF: none
Free water flushes: none

Hematology
Hgb:
Platelets:

Infectious
Temperature:
WBC:

# Ventilator aquired pneumona
Afever, leukocytosis and CXR findings c/w pneumonia
Cultures sent
Vanc/Zosyn 4/18 - ongoing
Narrow when culture data returns

Endocrine
Blood glucose range last 24 hrs: 100-200
Insulin: Intermediate SSI
Insulin requirements in last 24 hrs:
POC BG Schedule:

# History of IDDM
Holding metformin
on ISSI

MSK
PT/OT

# Pubic rami fx
Ortho following
Non operative management
PWB b/l

Access
l radial arterial line placed 4/17
right IJ central line placed 4/17

Disposition
TICU