Use the fоllоwing pаtient cаse fоr questions 10-12.A pаtient has been intubated due to an acute exacerbation of COPD. The patient is on:VC-CMV VT 450 mL f 14 BPM Ti 1 sec PEEP 5 cmH2O FiO2 0.24 Trigger 2 LPM and active humidification.The patient’s assessed parameters are as follows:PIP 30 cmH2O Pplat 15 cmH2O PEEPi 8 cmH2O VTe 450 mL Total f 14 BPMABG results are as follows:pH 7.31 PaCO2 70 mmHg PaO2 60 mmHg HCO3- 34 mEq/LIf this patient experiences trigger asynchrony, what is the most appropriate recommendation?
Review the fоllоwing pаtient infоrmаtion аnd document complete and thorough Admission Orders in the following essay question: Patient Information Patient Name: Gabriel Garcia-Perez Age: 45 years old Gender: M HPI: The pt is a 45 y/o M who presents s/p fall from a bicycle when riding to work this morning. He arrives via ambulance after a nearby witness called 9-11. He reports L arm pain and deformity and concern for a fracture that began after the fall this morning. He notes having multiple “scrapes” on both arms from the fall which resulted when he struck a parking block when attempting to avoid hitting a car. No active bleeding reported on arrival to the ER. From a witness report, the pt flew off the bike and landed on his L arm against a curb, subsequently rolling and did not appear to strike his head. He was wearing a helmet. The pain is worse with attempted movement of the arm, better without movement. No radiation of pain. The pain is currently rated 8/10. No report of neck pain, loss of consciousness, focal weakness anywhere, or memory loss. Associated symptoms include tingling of some fingers (1-3) of the L hand. Pt cannot assess ROM of L wrist due to pain and deformity, but states his hand can open/close with some pain. Pt denies nausea/vomiting, dizziness, confusion. Pt denies hx of a bleeding disorder, the use of any blood thinners, or use of any alcohol / drugs recently. Past Medical History (PMHx): Illnesses/Injuries: Patient reports a history of “high cholesterol” Hospitalizations: None Surgical History: None Screening/Preventive History: Pt is up-to-date on all vaccinations and preventative screenings, with exception of Tdap/Tetanus (last occurred at age 30). Medications (Prescription, Over the Counter, Supplements): -Fish oil daily (over-the-counter) to help with his cholesterol problem -No other medications Allergies (e.g. environmental, food, medication and reaction): NKDA Family Medical History: Mother (alive, age 70) has history of HTN Father (alive, age 71) has history of Diabetes Mellitus Type 2 Sister 1 (alive, 35) has history of depression and anxiety Sister 2 (alive, 39) - no known medical hx Daughter (alive, 24) - healthy No genetic disorders known in family Social History: Substance Use / Alcohol Use: No tobacco or substance abuse/use. Pt reports drinking 2-3 beers on Friday and Saturday nights Diet: No special diet reported Home Environment: Lives with wife in an apartment Occupation: General manager at Target Leisure Activities: Pt likes to ride his bike, go fishing, play soccer Exercise: Active 2-3x per week, daily bike rides otherwise Sleep: 6-7 hours per night Religion: Catholic Sexual: Sexually active only with his wife. No contraception or birth control used at this time ROS (Review of Systems): General: No weight loss, fever/chills, or night sweats. Skin: See HPI. No eczema, dry skin, or skin changes reported. HEENT: No headache, neck pain/stiffness, no sore throat. No vision changes or double vision. No congestion/runny nose. Respiratory: No cough, shortness of breath or wheezing. Cardiovascular: No chest pain or palpitations. Gastrointestinal: No n/v, diarrhea or constipation. No reported abdominal pain, flank pain, or change in bowel consistency. Genitourinary: No change in urination, dysuria, hematuria, or increased urinary frequency. Musculoskeletal: See HPI. No back pain or neck pain reported. Psychiatric: No depression, anxiety, or thoughts of self harm. Hematologic: No known easy bruising/bleeding, or gum bleeding. Endocrine: No hot or cold intolerance. Neurologic: See HPI. No dizziness, headache, confusion, or disorientation. No numbness or weakness reported. Physical Exam: General: Pt appears uncomfortable, in acute painful distress, and wearing normal street clothes on arrival. Pt is a WDWN male otherwise. Pt is alert and cooperative. Skin: Abrasions noted over B/L posterior aspects of arms, L worse than R. Abrasion also noted over L lateral deltoid/shoulder area. There is ecchymosis visible over posterior. No lacerations or active bleeding visualized otherwise. Otherwise warm skin, no rashes, normal turgor, no pallor or cyanosis throughout, including distal B/L LEs. Head: Normocephalic, atraumatic. No obvious signs of head trauma on exam such as contusion, abrasion, bruising, or laceration. Eyes: PEERLA B/L, EOMI B/L, sclera anicteric, conjunctiva clear. Ears, Nose, Throat: Normal ear, nose, and throat inspection. No pharyngeal erythema or lymphadenopathy noted. Ear canals patent B/L. Hearing grossly intact B/L. No hemotympanum, raccoon eyes, Battle sign, or otorrhea noted. Neck: Non-tender, c-spine ROM intact, no midline TTP, step-offs, or deformity. No visible skin changes, contusion, or abrasion. Pulmonary: Lungs clear to auscultation B/L, no crackles, wheezes, or rhonchi. Cardiac: Tachycardia noted, with normal rhythm, no murmurs, gallops, or rubs. Normal S1 and S2 otherwise. Peripheral Vascular: Capillary refill less than 2 seconds throughout distal extremities bilaterally. Peripheral pulses full and equal bilaterally. Abdomen: Soft, non-distended, non-tender. Normoactive BS presents in all 4 quadrants. No signs of abdominal trauma such as contusion, abrasion, or bruising. Rectal: Deferred GU: Normal external genitalia without evidence of trauma or injury. MSK: Cervical, thoracic and lumbar spine are without midline tenderness, step-off or deformity. Pelvis stable and without TTP. No crepitus, or depression appreciated. The left arm has obvious mid-forearm deformity (misalignment) with ROM of L elbow could not be easily assessed due to pain. R elbow, wrist and hand WNL. Left Wrist ROM appears limited due to pain. Fingers on B/L hands WNL, without deformity, and ROM is intact. There is no open laceration above deformity to suggest open fx. Overall, exam was limited of the L forearm due to pain and deformity. B/L upper extremities with superficial abrasions as noted previously. B/L lower extremities appear without evidence of contusion, deformity, or swelling. ROM intact B/L at hip, knee, ankle, foot B/L. Neuro: Pt is AAOX4. Memory and recall intact of the fall and recent events. Sensation noted to be decreased to digits 1-3 of L hand when compared to R and otherwise intact throughout upper and lower extremities. Strength 5/5 all extremities at major joints with exception of L elbow, wrist, hand which could not be fully assessed due to pain and/or obvious deformity limiting exam. Other than findings noted here, CN 2-12 exam is otherwise grossly intact. Gait normal and without ataxia. Reflexes 2+ in all extremities with exception of LUE which could not be assessed due to pain/swelling. No tremor or seizure activity noted. Psychiatric: Appropriate mood and affect for situation