16/37
ICU Intern ACCEPT NOTE
Chart reviewed, transfer note read and appreciated.
Briefly, this is a 23 year old white man with a history of Crohn's Disease
(age 16, recurrence age 19), panic disorder and possible recent depression,
admitted 8/21 after "syncopal" episode and seizure (tonic-clonic seizure
witnessed by 10 year old sister ) initially thought to be elavil toxicity, now
being transferred to the ICU for management of acute benzodiazepine
withdrawal. Patient has had panic attack for number of years and was
treated with Xanax by his father, a psychiatrist until recently. Patient
then began seeing Dr. Quan (?spelling) who prescribed Elavil
beginning 2 weeks ago. Patient began an increasing dosing scale of
Elavil and was taking 60mg PO QHS on the day of admission. Patient
denied benzo(diazepine) use, claimed last dose was May, 1993. Two days
prior to admission patient began experiencing dizziness upon standing,
and not quite feeling like himself. He was given 25 mg bethanacol when
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the orthostatic hypotension persisted for a second day. The day of
admission patient felt "jittery" and while standing, became pale &
lightheaded, fell to the ground and had a grand mal seizure witnessed by his
sister ("he was shaking like a fish out of water"). He was disoriented
and confused for 10 minutes after the seizure and then brought by EMS
to the ER. On presentation to the ER patient was orthostatic (160/80--->
130/80), mildly tachycardic and afebrile. He had a prolonged QRS complex
(0.11), and was admitted to telemetry for probable toxicity. Patient had
a negative Head CT(scan). While on telemetry patient became
disoriented and confused, anxious, and began hallucinating. Patient was
hypertensive and tachycardic and diagnosis of benzodiazepine withdrawal
despite patient initial denial of benzo(diazepine) ingestion (father states
patient did take benzo(diazepines) recently). Because of hallucinations
and paranoia patient was placed on 1:1 observation on telemetry by
psychiatry, and Ativan 2mg q 4hours was begun. Patient became
increasingly agitated and confused until frank delirium. He apparently
tried to put his hand through a window 8/23 at night despite 1:1. Patient
is now being transferred to the ICU for more intense observation and
monitoring.
Past Medical History Crohn's as above. On no medications. Currently
in remission
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All(ergies) ?immodium
Meds elavil 60mg QHS at home
Xanax ?
Family positive family history of panic disorder in paternal grand-
History father
Social patient is a recent college graduate who lives at home with
History parents and sister. Father is a practicing psychiatrist.
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