18/37
8/24/93
23 year old with benzodiazepine withdrawal. Delirious
tachycardia, (?illegible) normotensive. Continue
titrating dose. Plans reviewed, agree.
(Signature of Dr. ?Bertz/Burch ICU Senior
Admitting Resident)
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8/25/93 Intern Dr. Laurel Mayer note
7AM
Patient resting comfortably. easily arousable this morning. Remains
delirious. "I'm in the CBS studio in Burbank"
VITALS 160/60 (overnight ?-130/60) P(ulse) 110 R20
T (?max) 99 T(oral) 98 Input/Output 1600/1020
LUNGS Clear
HEART S1S2 normal I/VI Sinus Murmur @ Apex---->axilla
ABD Benign positive Bowel Sounds
EXT Positive diaphoresis, but greatly improved
Mental Status Oriented to person
continues waxing and waning
appears less physically agitated
LABS CSF : culture (?P)
#1 1 WBC, 2 RBC
#4 0 WBC, 1 RBC
protein 27
glucose 91
Impression 23 year old in acute benzodiazepine withdrawal
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1. Withdrawal overnight vitals were stable and improved from daytime
Patient received 2 mg Ativan at 7 (pm), 4 mg at 8, 2 mg at 9pm, 6 mg at 10:30
which held him until 6am today. Patient then received 4 mg and is currently as
described above. BP slightly increased this am. Will consider increasing Ativan
to 6mg q 4 (hours) if BP/P remains elevated or/and patient becomes increasingly
agitated.
LP results negative for blood (subarachnoid bleed) or infection
Continue seizure precautions
Tolerating Ativan. No need to switch to Xanax yet.
Will follow Creatine PhosphoKinase and hydrate to prevent
Rhabdomyolosis.
Signature of Intern Dr. Laurel Mayer, M.D.)
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