23/37
(conclusion of Intern Transfer Note, unsigned, 8/26/93)
Labs (?)significant for WBC - 17.7, nl(?normal) C7, SMAC (with
?CPK 26), negative Urinalysis
During course of hospitalization, patient put on Ativan & required doses
up to 14 mg over a 11 hour period. An LP was performed which (was)
negative. Eventually Ativan 2mg q 4 hours was all that was needed for
light sedation. this AM patient is calm. Negative hallucinations or
agitation. Answering questions appropriately & No Acute Distress. He
had some decreased urine output which was felt to be secondary to
dehydration. ? (?rhabdomyolosis) though CK only (approximately 2400.
He was hydrated vigorously & response of kidneys is being followed.
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Vital Signs Input/Output (?) 5700/811
Physical Exam - patient lying in bed with 4 point restraints, easily arousable
patient very appropriate
HEENT multiple abrasions on face by mouth &
forehead. hearing normal. PERLA, EOM intact
Heart - RRR, S1S2, OM/g/r (?)
lungs - CTA B
abd - positive bowel sounds, NT, ND, negative masses
extremities - negative edema, C/C
neuro - axox3 (alert and oriented), speech fluent & appropriate, (negative)
hallucinations (?) non focal
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Impression 23 year old with panic diagnosis being treated for
benzodiazepine withdrawal doing well
Plan - transfer to Psychiatry to work on issue
surrounding Benzodiazepine use
Genito-Urinary - follow Urinary Output & fluid status as well as Creatinine -
hydrate as needed. If no urinary output or inadequate
investigate possible causes of decreased output.
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