tokens: Admission Date : 2014-04-23 Discharge Date : 2014-04-28 Date of Birth : 1980-02-05 Sex : F Service : MEDICINE Allergies : Penicillins / Sulfonamides Attending : Louie A. Keith , M.D. Chief Complaint : Benzo overdose Major Surgical or Invasive Procedure : Intubation for airway protection History of Present Illness : HPI : Ms. Franklin is a 34 - year-old woman with Bipolar disorder and group home resident who by way of EMS for apparent alprazolam overdose . In the St. Margaret 's Center for Women & Infants , the patient was lethargic and unable to give a history . She was promptly intubated for airway protection and in order to administer charcoal . Patient was found at group home in am laying on floor by bed unresponsive , last seen awake 8 hours prior at dinner . Group home states that patient " may have taken too many Xanax . Patient has a history of suicidal ideations and self mutilation . Later patient told CMED CCU that she was feeling down and impulsively ingested 5 days worth of medications , she states that her intent at that time was to end her life . Past Medical History : 1. Bipolar disorder . 2. Asthma . 3. Posttraumatic stress disorder . 4. GERD 5. Chronic constipation from laxative abuse . Social History : Denies any recent use of EtOH or illicit drugs . Per OMR , h/o sporadic marijuana use . Now living at the DBT House on Treva Williamson in Westborough . In currently in a relationship with a man whom she met during a previous inpt admission . Per OMR , the patient is currently not in contact with her family . She was raised in multiple foster care homes because her mother could not care for her . She was physically abused and severely neglected as a child and been sexually assaulted . She has no current romantic relationship . She has never been married . She has completed up to the tenth grade of high school . She has no current legal issues . Family History : Substance abuse in mother and brother . Two sisters with h/o depression and suicidality . Physical Exam : VS 95.4 HR 62 BP 99/70 RR 20 O2Sat 100% Gen : Intubated and sedated HEENT : ATNC , Pupils dialted at 5 mm but minimally reactive , anicteric Chest : CTA ant/lat Cor : RR nl S1 S2 no m Abd : Soft , nd , hypoactive bowel sounds Ext : WWP , multiple linear scars and burns on hands and arms Neuro : Sedated , DTRs : Skin : No rashes or petechiae , linear and burn scars as above Pertinent Results : 2014-04-23 07:56 AM WBC - 9.4 # RBC - 4.75 HGB - 14.7 HCT - 42.2 MCV - 89 MCH - 30.9 MCHC - 34.8 RDW - 13.6 2014-04-23 07:56 AM PLT COUNT - 330 2014-04-23 07:56 AM NEUTS - 73.0 * LYMPHS - 21.8 MONOS - 3.8 EOS - 1.1 BASOS - 0.3 2014-04-23 07:56 AM ASA - NEG ETHANOL - NEG ACETMNPHN - NEG bnzodzpn - NEG barbitrt - NEG tricyclic - POS 2014-04-23 07:56 AM LITHIUM - LESS THAN 2014-04-23 07:56 AM DIGOXIN -< 0.2 * 2014-04-23 07:56 AM GLUCOSE - 116 * UREA N - 14 CREAT - 1.0 SODIUM - 137 POTASSIUM - 4.5 CHLORIDE - 105 TOTAL CO2 - 20 * ANION GAP - 17 2014-04-23 07:56 AM CALCIUM - 9.7 PHOSPHATE - 3.7 MAGNESIUM - 2.1 2014-04-23 07:56 AM ALT ( SGPT )- 21 AST ( SGOT )- 40 ALK PHOS - 70 AMYLASE - 59 TOT BILI - 0.4 2014-04-23 07:56 AM LIPASE - 66 * 2014-04-23 08:00 AM URINE BLOOD - NEG NITRITE - NEG PROTEIN - NEG GLUCOSE - NEG KETONE - TR BILIRUBIN - NEG UROBILNGN - NEG PH - 6.5 LEUK - NEG 2014-04-23 08:13 AM URINE bnzodzpn - POS barbitrt - NEG opiates - NEG cocaine - NEG amphetmn - NEG mthdone - NEG 2014-04-23 01:38 PM CK ( CPK )- 4713 * 2014-04-23 03:45 PM URINE UCG - NEGATIVE 2014-04-23 03:56 PM D-DIMER - 7998 * CXR : Probable ateletasis of lingula , consistent with pneumonitis EKG : NSR R 60 Normal axis , intervals , incomplete RBBB , flat T aVL , V2 , TWI V1 CT Chest - shows bilateral segmental , subsegmental PEs B/L LE LENIs - negative Brief Hospital Course : CMED CSRU Course : Patient was intubated in John for airway protection and administation of charcoal . Toxicology consulted and felt that patient most likely had benzo overdose . ABG revealed widened A-a gradient so a d-dimer was sent which was elevated . Patient had CTA which showed bilateral pulmonary embolisms . Patient was started on heparin drip and bilateral lower extremeties were done which were negative for DVT . Patient was exubated after 1 day in ICU after waking up . Overnight in the ICU patient was noticed to have painful bullae on hands and arm along with swelling . Dermatology and plastic surgery were consulted who felt that symptoms were due to trauma ; it was not felt that patient had compartment syndrome . Patient was splinted and UE were kept elevated . Patient was gradually put back on her outpatient xanax dose of 1 mg qid and clozaril was restarted . Patient was transferred to floor after spending 1 day in the ICU . Once on the floor patient stable . Plastic did not feel that patient had any compartment syndrome and recommended aggresive upper extremity elevation for swelling reduction . While on the floor patient 's hands improved with good range of motion of left hand , however Jones some poor range of motion of right . X-ray of the hands and wrist were obtained which were negative . Patient seen by PT and OT who recommended hand exercises and splints for patient . Patient was put on coumadin that was bridged with lovenox unti lINR theraputic 01-23 . Patient conitnued to have SI while on floor and was transferred to psychiatry . While on the floor patient 's urinalysis suggestive of UTI and was put on 6 day course of levofloxacin . Medications on Admission : Propanolol XL 80 mg qd Modifinal 100 mg po qd Lamictal 100 mg po bid Alprazolam 1 mg po qid Senna Trazadone 200 mg po qhs Clomipramine 100 mg po qhs Pantopraozle 40 mg po qd Clozapine 300 mg po qhs Folate 1 mg po qd Multivitamin Discharge Medications : 1. Acetaminophen 325 mg Tablet Sig : 1-2 Tablets PO Q4-6H ( every 4 to 6 hours ) as needed . 2. Lamotrigine 100 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) . 3. Pantoprazole Sodium 40 mg Tablet , Delayed Release ( E.C. ) Sig : One ( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hours ) . 4. Folic Acid 1 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . 5. Multivitamin Capsule Sig : One ( 1 ) Cap PO DAILY ( Daily ) . 6. Senna 8.6 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) . 7. Clozapine 25 mg Tablet Sig : One ( 1 ) Tablet PO HS ( at bedtime ) . 8. Warfarin Sodium 3 mg Tablet Sig : One ( 1 ) Tablet PO at bedtime . 9. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ) . 10. Trazodone HCl 100 mg Tablet Sig : Two ( 2 ) Tablet PO HS ( at bedtime ) as needed . 11. Alprazolam 1 mg Tablet Sig : One ( 1 ) Tablet PO QID ( 4 times a day ) . 12. Levofloxacin 500 mg Tablet Sig : One ( 1 ) Tablet PO Q24H ( every 24 hours ) for 3 days . 13. Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : Two ( 2 ) Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) as needed . 14. Nicotine 14 mg / 24 hr Patch 24 HR Sig : One ( 1 ) Patch 24 HR Transdermal DAILY ( Daily ) . Discharge Disposition : Extended Care Discharge Diagnosis : Benzodiazapine Overdose Traumatic / pressure bullae Bipolar Disorder Discharge Condition : Stable - Swelling in hands reduced and range of motion continue to improve . Discharge Instructions : Please continue to take coumadin as directed by your doctors until told to stop for clots found in your lungs . Please continue to take antibiotics as directed for urinary tract infection for 3 more days . Please conitnue to keep hands elevated in bed until follow up appointment with plastic surgery . Followup Instructions : Patient will be admitted to psychiatry service Patient should follow up with at plastic surgery clinic in 2 weeks . Appointment setup for Tues. 05-13 at 10 am . 3rd floor Henderson Building with Dr. Black ( 650 ) 866-1361 Raymond William MD 50-154 Completed by : Simon Claudine Audrey MD 82-812 2014-04-28 @ 1227 Signed electronically by : DR. Tracey Mccourtney on : MON 2014-05-05 10:26 PM ( End of Report )