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CONTINUATION SHEET
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8/27/93 R2 (second year resident) note
7pm
Called To See Patient during my Psychiatric workup, after final
diagnostic assessment (?unclear abbreviation)
Physical Exam (per Dr. Motz). Events of afternoon as follows:
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~ 1:00-1:20 Patient seen by Beth, R.N. History taken
~ 1:15-3:15 I sat with patient in his room for initial examination
Patient was Alert & Oriented, pleasant & cooperative,
and without any complaints. Please see Psych workup
~ 3:15 I left patient room with patient. He went to phone to
call his father, and then had vitals taken.
vital signs stable.
~ 3:40 I returned to patient room. I called to him in
the bathroom, and asked for his father's office
phone #. Patient answered that he did not know
the number. I asked why not, and he stated
that he just did not know it. His voice was calm.
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As I was writing my note, it came to my attention that patient had been coded after found in the bathroom unresponsive. I provided relevant information to code team.
My initial diagnostic impression was that this was a 23 year old male with
almost daily panic attacks x 2 years, and signs and symptoms (of)
depressive diagnosis(?) x 6 months, & chronic Benzodiazepine use x
2 years (until at least 2 weeks Prior To Admission)
|who was admitted 6 days ago following a seizure, treated x 6 days for
presumed Benzodiazepine withdrawal, and transferred to Psychiatry.
Patient denied recent Benzodiazepine or other drug use. Initial plan
was to complete medical assessment, continue treatment for
Benzodiazepine withdrawal, and begin workup for signs and symptoms
(of) panic, & depression, including further history, organic workup.
S. Seidman, PGY2, Psychiatry
Ann Swen(?), M.D.
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