17/37
(Continuation of Intern Admission Note to ICU 8/24/93)
Physical Exam Patient is a young male with obvious abrasions on his face,
restrained in bed, babbling about a production, with his eyes intermittently
closing
Vitals: Pulse 103 BP 150/70 R20 T 99.5 (PR)
Heent abrasions on nose, cheeks, edges of mouth, PERLA, Unable to
formally test EOM (?eye movements), but appears to move his eyes
in all directions. mouth: throat non-injected no ulcers. no evidence of
tongue biting.
LUNGS clear
Heart s1s2 normal. II/VI sm (sinus murmur) @ apex-->axilla no clicks - no opening
snap. negative q/r
ABD soft, non tender, non distended no guarding no rebound.
no HSM. positive BS
Ext no c/c/e (?). when awake--->tremors of both hands.
NEURO oriented to name only. waxing and waning consciousness -
speech fluent but nonsensical, tangential. acute hallucinations.
responsive to some commands.
Cranial Nerves
II-XII grossly intact as observed. Patient not able to cooperate
with exam.
Motor appears full strength
Click here for image
Click here for previous page
15.1
LABS: ADMISSION 17.7>------<253 137 101 14 <84 10.1 224 .6/.1 31
44.3 4.1 21 1.2 2.7 8.0 93 199
12.2 5.1 25 26
8/22 137 101 8 <101
13.8 3.7 27 1.1
8/23 9.0>-------<218
40.3
Urinalysis negative
Head CT negative EKG
CXR
Impression/ 23 year old white male with history of Crohn's disease, panic
attacks and recent (current) depression admitted status post grand mal
seizure and feeling jittery, now known to be benzodiazepine withdrawal.
Click here for image
Click here for previous page
1. Benzodiazepine withdrawal treatment is replacement benzodiazepine and
supportive care. Because Xanax is only PO, will cover initial period with
Ativan which can be given IV and its entry into circulation is ensured.
Patient's delirium puts him at aspiration risk which also makes PO
Xanax a suboptimal choice.
- Ativan q(every) 2 (hours) 2 mg to treat (High) BP,
(High) Heart Rate, agitation
Will do Lumbar Puncture emergency to rule out other etiology of change in
mental status.
Also to (?rule out) blood secondary (to) subdural hematoma secondary
(to) head injury from fall (seizure)
2. Seizure no evidence of seizure activity. Seizure secondary to
withdrawal. Ativan should prevent further seizures. Nothing by mouth,
and seizure precautions however
3. To Psychiatry (ward) when stable.
Signature of Laurel Mayer, M.D.
Click here for image
Click here for previous page
Click here for next page
Click here for beginning of chart