Age: 46.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Blood urea increased, Brain natriuretic peptide normal, Carbon dioxide decreased, Chest X-ray abnormal, Chest pain
Clinical narrative: MD Physician Hospitalist H&P    Addendum Date of Service:  02/01/22 1929         Hide copied text  Hover for details    Hospital Medicine Admission History & Physical     Patient:   DOB:   MRN:   Date: 2/1/2022 Room:   PCP:  APRN (General)   Chief Complaint:  Drug overdose   History Of Present Illness: Patient is a 47 y.o. male with HTN, Hep C, on methadone,seizure disorder. Patient reported accidentally took 60 tabs of norvasc 10 mg at 5 AM. Today. At ER, he was anxious and reported chest pain. When I saw patient, he was not responsive and nursing staff reported that he earlier got narcan and had a seizure episode after the narcan was given. There was no vomiting, no fever, he was given calcium gluconate, glucagon with some improvement in BP. He was started on levophed iv drip. ER spoke with poison control. Will admit to FACILITY       Past Medical History:  Patient  has a past medical history of Anxiety, Arthritis, Blood clots, Brain injury, Hepatitis C, Hernia, abdominal, Hypertension, IV drug user, Kidney disease, Marijuana abuse (7/18/2017), MRSA infection (6/10/2010), MRSA nasal colonization (6/15/2010), Neuropathy, Organic brain syndrome, Pneumonia, Seizure, and Streptococcus pneumoniae pneumonia (7/27/2018).   Past Surgical History:  Patient's  has a past surgical history that includes Hx Lung Surgery; Hx Broken/Fx Bones; Hx Other Surgical History; Hx Thoracotomy; Hx Breast Surgery; and Biopsy.   Family History:   Patient's family history includes Cancer in his paternal grandfather; Endocrine Disorder in his mother; Hypertension in his father; Renal Disease in his mother.      Social History:  He  reports no history of alcohol use.  He  reports previous drug use.  He  reports that he quit smoking about 14 months ago. His smoking use included cigarettes. He has a 3.75 pack-year smoking history. His smokeless tobacco use includes snuff.    Allergies:  Codeine    PTA Medications:  Prior to Admission Medications Prescriptions Last Dose Informant Patient Reported? Taking? QUEtiapine (SEROQUEL) 400 mg tablet     No No Sig: Take 1 Tablet by mouth At bedtime. albuterol (VENTOLIN HFA) 90 mcg/Actuation inhaler     No No Sig: Take 2 Puffs by inhalation Every 4 hours as needed. amLODIPine (NORVASC) 10 mg tablet     No No Sig: Take 1 Tablet by mouth Daily. guaiFENesin (MUCINEX FAST-MAX CHEST-CONGEST) 100 mg/5 mL oral liquid     No No Sig: Take 10 mL by mouth Every 6 hours as needed. levETIRAcetam (KEPPRA) 500 mg     Yes No Sig: Take 500 mg by mouth At bedtime. meclizine (ANTIVERT) 12.5 mg tablet     No No Sig: Take 1 Tablet by mouth Three times a day as needed for Nausea. methadone 10 mg/5 mL     Yes No Sig: Take 120 mg by mouth Daily. Indications: dependence on opioid-type drugs needle, disp, 18 G (BD REGULAR BEVEL NEEDLES) 18 gauge x 1 1/2" Ndle     No No Sig: 1 mL Every two weeks. polyethylene glycol 3350 (GLYCOLAX, MIRALAX) 17 gram packet     Yes No Sig: Take 34 g by mouth Daily. Indications: constipation, may take over the counter sildenafiL (VIAGRA) 100 mg tablet     No No Sig: Take 1 Tablet by mouth As directed. 1 po 30 mins before intercourse prn syringe with needle, safety (BD ECLIPSE LUER-LOK) 3 mL 22 gauge x 1 1/2" Syrg     No No Sig: 1 Units Every two weeks. testosterone cypionate (DEPOTESTOTERONE CYPIONATE) 200 mg/mL injection     No No Sig: Administer 1 mL intramuscularly Every two weeks.  Facility-Administered Medications Last Administration Doses Remaining azithromycin (ZITHROMAX) tab 500 mg None recorded 1        Review of Systems:  Review of Systems Unable to obtain due to altered mental state   Physical Exam: Blood pressure (!) 91/55, pulse 79, temperature 98.3 °F (36.8 °C), temperature source Oral, resp. rate 12, height 6' 3" (190.5 cm), weight 115.7 kg (255 lb), SpO2 93 %. Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is not toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: Tympanic membrane and external ear normal.     Left Ear: External ear normal.     Nose: No rhinorrhea.     Mouth/Throat:     Pharynx: No oropharyngeal exudate.  Eyes:     General: No scleral icterus.    Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No carotid bruit.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: No respiratory distress.     Breath sounds: No stridor. No wheezing, rhonchi or rales.  Chest:     Chest wall: No tenderness.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness. There is no right CVA tenderness, left CVA tenderness, guarding or rebound.  Musculoskeletal:        General: No swelling, tenderness, deformity or signs of injury.     Cervical back: No rigidity.     Right lower leg: No edema.     Left lower leg: No edema.  Lymphadenopathy:     Cervical: No cervical adenopathy.  Skin:    Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced or pale.     Findings: No bruising, erythema, lesion or rash.  Neurological:     Cranial Nerves: No cranial nerve deficit.     Sensory: No sensory deficit.     Motor: No weakness.     Coordination: Coordination normal.     Gait: Gait normal.     Deep Tendon Reflexes: Reflexes normal.     Comments: Lethargic , unresponsive  Psychiatric:     Comments: Lethargic , unresponsive          Labs:   CBC:   Lab Results Component Value Date/Time   WBC 15.3 02/01/2022 1526   RBC 5.19 02/01/2022 1526   HGB 15.7 02/01/2022 1526   HCT 45.4 02/01/2022 1526   MCV 87.4 02/01/2022 1526   MCH 30.2 02/01/2022 1526   MCHC 34.6 02/01/2022 1526   RDW 15.6 02/01/2022 1526   MPV 8.8 02/01/2022 1526   PLATELETCNT 303 02/01/2022 1526   BMP:   Lab Results Component Value Date/Time   SODIUM 134 02/01/2022 1526   POTASSIUM 4.5 02/01/2022 1526   CHLORIDE 100 02/01/2022 1526   CO2 21 02/01/2022 1526   GLUCOSE 137 02/01/2022 1526   BUN 32 02/01/2022 1526   CREATININE 2.5 02/01/2022 1526   CALCIUM 9.1 02/01/2022 1526   OSMOLALITY 277 02/01/2022 1526   BC 13 02/01/2022 1526   Cardiac Enzymes:   Lab Results Component Value Date/Time   CK 2321 06/08/2011 0440   CKMB 40.9 06/08/2011 0440   TROPONINI <0.03 02/01/2022 1808   ABG's:   Results for orders placed or performed during the hospital encounter of 02/01/22 (from the past 336 hour(s)) RT Blood Gases   Collection Time: 02/01/22  7:26 PM Result Value Ref Range   PH BLOOD 7.25 (L) 7.35 - 7.45   PCO2 ARTERIAL 50 (H) 35 - 45 mm[Hg]   PO2 50 (LL) 80 - 100 mm[Hg]   HCO3 20.0 (L) 22.0 - 28.0 mmol/L   BASE EXCESS -5.6 mmol/L   %O2 SATURATION 84.8 (LL) 95.0 - 100.0 %   O2 4.00     DRAW SITE RT Radial     O2 DEVICE 1 Cannula     Urinalysis: No results found for this visit on 02/01/22 (from the past 72 hour(s)).   Imaging:  X-Ray:chest   Questionable areas of mild patchy increased density at the lung bases which may be related to mild atelectasis or infiltrate.  Otherwise, stable chronic changes.   Ct head: pending    ASSESSMENT/PLAN:   Problems and Relevant Co-morbid conditions:: Principal Problem:   Calcium channel blocker overdose Active Problems:   Hypotension due to drugs   AKI (acute kidney injury)   Hepatitis C   Seizure   Altered mental state       * Calcium channel blocker overdose Patient informed ER staff that it was accidental overdose but I doubt that Admit to FACILITY He was already given glucagon, calcium gluconate in ER Will start on levophed iv drip. I requested ER physician to place a central line Will start on insulin iv drip. Uptodate recommends 0.5 unit/kg/hour . Will try to be conservative for now and will start at 0.1 units/kg /hour and watch out for hypoglycemia Will give D5 NS. hypogycemia protocol Consult intensivist     AKI (acute kidney injury) Most likely related to hypotension Consult renal. Follow BMP   Hypotension due to drugs Currently on levophed iv drip Treat underlying calcium blocker overdose Admit to MICU   Altered mental state He is difficult to wake up. Had seizure earlier . Unclear if this is post ictal Will get ct head, abg   Seizure He is on keppra at home. He had seizure episode in ER after he was given narcan Will give keppra iv. Consult neurology   Hepatitis C Follow up with pcp     Full code    DVT ppx - heparin   Critical care time: 55 minutes   --- Signed, MD 2/1/2022    addendum. Patient remains unresponsive. ABG showed resp failure hypoxia and hypercapnea. Patient intubated by ER physician. Will need to follow abg, repeat chest xray. Will inform family and update them. BP improving and insulin drip not yet started. Will hold insulin iv drip and will give this only if BP drops inspite levophed iv drip. I spoke with patient's father and made aware of his admission and critical state.   Critical care time: 30 minutes  Troponin I Order:   Status: Final result   Visible to patient: Yes (not seen)   Next appt: 02/28/2022 at 08:15 AM in Family Medicine (APRN)   0 Result Notes   Ref Range & Units 4 d ago TROPONIN I 0.00 - 0.02 ng/mL <0.03  Beta-Hydroxybutyrate, S/P Order: 151579374 Status: Final result   Visible to patient: Yes (not seen)   Next appt: 02/28/2022 at 08:15 AM in Family Medicine (APRN)   0 Result Notes   Ref Range & Units 4 d ago BETA-HYDROXYBUTYRATE, S/P 0.02 - 0.27 mmol/L 0.13  Resulting Agency  LAB     Specimen Collected: 02/01/22 18:08 Last Resulted: 02/01/22 20:51    Lab Flowsheet   Order Details   View Encounter   Lab and Collection Details   Routing   Result History      Result Care Coordination   Patient Communication   Released Not seen Back to   Beta-Hydroxybutyrate, S/P Order: 151579374 Status: Final result   Visible to patient: Yes (not seen)   Next appt: 02/28/2022 at 08:15 AM in Family Medicine (APRN)   0 Result Notes   Ref Range & Units 4 d ago BETA-HYDROXYBUTYRATE, S/P 0.02 - 0.27 mmol/L 0.13  Resulting Agency  LAB     Specimen Collected: 02/01/22 18:08 Last Resulted: 02/01/22 20:51    Lab Flowsheet   Order Details   View Encounter   Lab and Collection Details   Routing   Result History      Result Care Coordination   Patient Communication     Result  Narrative & Impression                         Medical Center                                                                      Radiology   PATIENT NAME:                    MR#:    PROCEDURE DATE:  02/02/2022                       ACCOUNT#:    ACCESSION #:                               ROOM#:    ORDERING PHYS:  MD   Comparison:  None     INDICATION:  OG tube placement   Findings: AP view of the lower chest upper demonstrates a nasogastric tube in position with tip in the stomach there are postoperative changes from prior lumbar fusion and IVC filter placement     IMPRESSION: 1.  OG tube in position with tip in the stomach.                   THIS IS AN ELECTRONICALLY VERIFIED REPORT                    2/2/2022 7:19 AM:  MD     MD    DD:  02/02/2022 TD:  02/02/2022 JOB #:                                           Radiology Page 1    of   1                                                          COPY  Result History  XR KUB Portable (Order #) on 2/2/2022 - Order Result History Report   Hard Copy Result Report  Open Hard Copy Result Report (Order #- XR KUB Portable)  PACS Images   Show images for XR KUB Portable  Exam Details  Performed Procedure Technologist Supporting Staff  XR KUB Portable RT(R) RT(R)     Appointment Date/Status Modality Department  2/2/2022     Completed MAIN X-RAY PORTABLE 1 MAIN X-RAY     Begin Exam End Exam Begin Exam Questionnaires End Exam Questionnaires 2/2/2022  4:58 AM 2/2/2022  5:51 AM BEGIN EXAM TRANSPORT  XRAY END EXAM                            Medical Center                                                                       Radiology   PATIENT NAME:                    MR#:    PROCEDURE DATE:  02/02/2022                       ACCOUNT#:    ACCESSION #:   ROOM#:    ORDERING PHYS:  MD   Comparison:  None     INDICATION:  OG tube placement   Findings: AP view of the lower chest upper demonstrates a nasogastric tube in position with tip in the stomach there are postoperative changes from prior lumbar fusion and IVC filter placement     IMPRESSION: 1.  OG tube in position with tip in the stomach.                                                                                      Radiology   PATIENT NAME:                     MR#:    PROCEDURE DATE:  02/03/2022                       ACCOUNT#:    ACCESSION #:   ROOM#:    ORDERING PHYS:  MD   Single view chest   History:  Respiratory failure   Comparison:  02/02/2022   Findings:  The tip of the endotracheal tube is at the proximal right mainstem bronchus.  Enteric tube is partially seen.  Bibasilar air space disease/pulmonary edema with a shallow lung inspiration and additional findings are similar.   Impression: The endotracheal tube terminates at the proximal right mainstem bronchus.  Bibasilar air space disease and/or pulmonary edema is again noted.                   THIS IS AN ELECTRONICALLY VERIFIED REPORT                 2/3/2022 7:16 AM:  MD   MD     DD:  02/03/2022 TD:  02/03/2022 JOB #:                                           Radiology Page 1    of   1                                                          COPY   Result History  XR Portable Chest (Order # ) on 2/3/2022 - Order Result History Report  Hard Copy Result Report  Open Hard Copy Result Report (Order # - XR Portable Chest)  PACS Images   Show images for XR Portable Chest  Exam Details  Performed Procedure Technologist Supporting Staff  XR Portable Chest       Appointment Date/Status Modality Department  2/3/2022     Completed MAIN X-RAY PORTABLE 1 MAIN X-RAY     Begin Exam End Exam Begin Exam Questionnaires End Exam Questionnaires 2/3/2022  7:13 AM 2/3/2022  7:13 AM  BEGIN EXAM TRANSPORT   XRAY END EXAM                            Medical Center                                                                       Radiology   PATIENT NAME:                     MR#:    PROCEDURE DATE:  02/03/2022                       ACCOUNT#:    ACCESSION #:   ROOM#:    ORDERING PHYS:  MD   Single view chest   History:  Respiratory failure   Comparison:  02/02/2022   Findings:  The tip of the endotracheal tube is at the proximal right mainstem bronchus.  Enteric tube is partially seen.  Bibasilar air space disease/pulmonary edema with a shallow lung inspiration and additional findings are similar.   Impression: The endotracheal tube terminates at the proximal right mainstem bronchus.  Bibasilar air space disease and/or pulmonary edema is again noted.                   THIS IS AN ELECTRONICALLY VERIFIED REPORT                 2/3/2022 7:16 AM:  MD     MD     DD:  02/03/2022 TD:  02/03/2022 JOB #: