• Image-1455

  • Ben
    Client ID 001

  • Name:
    Ben
    Age:
    20
    Primary Diagnosis:
    Infective endocarditis, L CVA
    Gender Identity:
    Male
    Insurance: 
    Medicaid
    Pronouns:
    He/him/his
    Referring Physician: 
    Trevor Wilcox, MD
    Race/Ethnicity:
    White

  • History of present illness:
    20yo WM admitted to the hospital 1 week ago in an unconscious state with agonal respirations. Intubated on arrival and extubated 5 days later. Diagnosed with endocarditis, critical aortic stenosis, L MCA aneurysm resulting in R hemiplegia, and septic shock.

    Past medical/surgical history:
    HIV+, substance abuse disorder, potential depression, + smoker 2 PPD

  • Marital status: Not married, with girlfriend of two years

    Primary language: English

    Prior level of function: Independent with ADLs, cooking, household chores, and driving. Per father, able to perform financial duties but often neglected them (father assisted when needed).

    Employment/work/school: Left school in 10th grade, currently unemployed.

    Play/leisure/interests: Enjoys playing electric guitar for his band and listening to rock music.

    Environmental factors: Lives with father on second floor of rental home. 13 steps to their rental unit, R handrail. Once in rental unit, bedroom, bathroom, and all living spaces are on one floor. Tub/Shower combo. No DME. Father works full-time but is supportive and has been urging him to seek outpatient treatment for his IV drug abuse and methamphetamine use for some time without success.

  • OOB
    Monitor orthostatic vital signs
    Sternal precautions
    PICC line
    NG tube
    Ground solids and nectar thick liquids

  • Lopressor
    Nicotine patch
    Oxycodone

  • MRI: extensive L MCA CVA
    Chest x-ray: atelectasis of B lower lobes

  • Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.

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