PATIENT:Carolina Spencer REASON FOR ENCOUNTER: Assistance with tracheostomy management. HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old female admitted to McGraw Hospital on July 17th with acute ischemic CVA and DKA. The patient has a very complicated medical history, including respiratory failure, on prolonged mechanical ventilation. She underwent tracheostomy placement on July 19th and was weaned from mechanical ventilation within 12 hours. She was also diagnosed with hospital-acquired pneumonia, multi-organism, and pulmonary embolism by CTPA. She is currently on heparin drip, while started on Warfarin. She also has end-stage renal disease and is on hemodialysis. PAST MEDICAL HISTORY: In addition to the above, the patient was found to have some type of intracardiac shunt per echocardiogram, not otherwise defined; atherosclerosis of the internal carotid arteries; positive lupus anticoagulants; and long-standing history of diabetes mellitus, type II.
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[Solved]: PATIENT:Carolina Spencer REASON FOR ENCOUNTER:…