[Verified Answer]: ADMITTING HISTORY A 22-year-old Caucasian man…

ADMITTING HISTORY A 22-year-old Caucasian man had a long history of alcohol abuse. While in middle school, he and his friends stole their parents’ beer and drank regularly. By the time, he was a senior in high school; he was drinking beer and whiskey almost daily. When he was drinking, he often became mean and got into fights. Although he was well built and considered attractive, he generally could not maintain a long-term relationship with any of the girls whom he dated in high school. At graduation, however, he was dating the woman whom he ended up marrying 7 months into their relationship. The marriage was a stormy one. His wife was well known to the social workers who answered the hot line at the local crisis center. On several occasions, his wife summoned the police to the couple’s mobile home with reports of spousal abuse. Once the man waved a small handgun at her and accidentally shot a hole through their kitchen wall. He always apologized extensively to his wife after a major incident and promised, to no avail, to stop drinking. Within 1 year of their marriage, he lost his job as a carpenter because he missed too many days of work. Then, 15 months after their wedding, his wife filed a restraining order against him, filed for divorce, and moved back in with her parents. He continued to drink heavily as he worked various minimum-wage jobs for the next 2 years. The local union laid him off from his position as an unskilled laborer. Using his unemployment checks to subsidize his habits, he spent most of his days and evenings in local bars drinking, playing cards, and shooting pool. He lost his driver’s license 5 weeks before this admission because of driving under the influence of alcohol. On the day of this admission the man started drinking heavily around 4 pm. By 23:30 hours, he was at a local dance club, extremely intoxicated. He was using foul language, bumping into people, yelling insults at the band, and constantly trying to start fights with other customers. The bouncer quickly ushered him off the premises. The weather of that night was cold and rainy as he hitchhiked along a country road trying to get home. He stumbled, staggered, and yelled profanities at the cars as they drove past. A witness later told the police that he appeared to be daring the cars to hit him. Approximately 20 minutes after he was ejected from the dance club, he was hit by a pickup truck. The ambulance crew found him 35 yards from the road, lying in a ditch. PHYSICAL EXAMINATION When the man was brought into the emergency room, he was unconscious but breathing on his own through a nonrebreathing mask. He had numerous scrapes and lacerations on his face, anterior chest, and legs. Both his upper and lower front teeth were broken at the gum lines. Paradoxical chest movement could clearly be seen over most of his anterior chest. His skin appeared pale and cyanotic, and the smell of alcohol radiated strongly from his body. His blood alcohol level was 0.31%. The patient’s vital signs were as follows: blood pressure 165/92, heart rate 120 bpm, respiratory rate 26/minute and shallow, and rectal temperature 36.2C (97.2F). His weight was approximately 86 kg (190 lb). Breath sounds were diminished bilaterally. A chest x-ray showed extensive multiple double rib fractures of the right and left anterior and lateral ribs, between ribs 4 and 9. No pneumothorax was visible. His sternum was fractured in three separate places. Increased densities, consistent with atelectasis, were visible throughout both lung fields in the chest x-ray. The patient’s ABGs on an FIO2 = 0.8 by nonrebreathing mask were as follows: pH 7.17, PaCO2 82 mm Hg, HCO3– 27 mEq/L, and PaO2 37 mm Hg. His oxygen saturation measured by pulse oximetry (SpO2) was unattainable. Figure: Chest x-ray of a 22-year-old man with flail chest Based on the above clinical data, how would you SOAP this patient? (SOAP 1) 24 HOURS AFTER ADMISSION The patient’s condition was still classified as serious and unstable. He was on a mechanical ventilator in the control mode. A pulmonary artery catheter, a central venous pressure catheter, and an arterial line were in place. Although the patient drifted in and out of consciousness, he was on a pancuronium (Pavulon) drip and was unable to move. No paradoxical movement of the chest was detected. His skin still appeared pale and cyanotic, and his neck veins were distended. The patient’s vital signs were as follows: blood pressure 100/65, heart rate 145 bpm, and a control mode mechanical ventilation respiratory rate of 12/minute. His temperature was unchanged. No breath sounds could be heard over the right lung field. Diminished breath sounds were audible over the left lung lobes. Fine and course crackles also could be heard over the left lung fields. A portable chest x-ray taken earlier that morning showed the left lung to be partially aerated with the patches of atelectasis; the right lung was shown to be comp