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February 8, 2016

Rukeme Ogaga MS3


Patient: SP
Department of Medicine, Adult In-Patient
Identifying Data: SP is a 52yo AAF, single, domiciled, with a PPH of bipolar 1
disorder, depressed type and PMH of HTN, Hypothyroidism, and T2DM BIB EMS 2/2
being found unresponsive by family member and admitted for altered mental
status. Psychiatry was consulted for discharge clearance.
CC: psychiatric clearance
Informants: family, EMS
HPI: SP is a 52yo AAF, single, domiciled, with PPH of Bipolar 1 Disorder, depressed
type well known by Dr. Pierre Paul on 12 CHC who was brought in for altered mental
status. As per EMS, family was unable to wake patient up from sleep which caused
an alarm warranting a 911 call. Upon EMS arrival, finger stick of 24mg/dl was noted
and patient was two D50 boluses and 2 Narcan (Naloxone) pushes. In the ED,
patient received CT head w/out contrast which was negative for any acute changes.
Patient was also found to be hypothermic (92.2F), placed on warming blanket and
intubated for airway protection followed by versed drip. There was questionable
bilateral infiltrates on chest xray therefore Vancomycin + Cefepime was to be
started empirically in the ED, however, infectious diseases was consulted
suggesting no apparent pneumonia and abx were subsequently held off. Neurology
evaluated the patient and suspected drug overdose being the primary reason for
hypoglycemia causing AMS.
Collateral Information including psychiatric history was obtained from patient
chart.
Hospital Course
Patient was immediately transferred to M-ICU for a trial of a sedation break on
2/3/2016 however she panicked and became restless, attempted to pull out the
endotracheal tube, sit up and get out of bed while still on vent. Patient was
restrained by staff and then wrist and vest restraints were applied. IV sedation was
started again but patient continued to be restless requiring Haldol, Ativan, and
Benadryl.
Past Psychiatric History: Bipolar 1 Disorder, depressed type
Past Medical history: HTN, T2DM, Anemia unspecified type, Hypothyroidism,
Diabetic Ulcer s/p left 4th toe amputation
Family History:
Psychosocial History:
Substance Abuse History:

MSE (on 2/8/2015 when Psych Consult was done):


Appearance: appears stated age, well groomed, short hair
Behavior: good eye contact
Cooperation: cooperative and smiling
Speech: slow, monotone, clear, limited inflection
Thought Content: relevant response to questions w/out evidence of ruminations or
obsessions, non-bizarre delusions present When Im outside, people are looking at
me like and think Im crazy.
Thought Process: goal oriented, logical, no thought blocking or flight of ideas
Affect: mood congruent
Mood: labile
Perception: denies auditory, visual, or gustatory hallucinations
Level of Consciousness: alert
Insight: fair; asked attending will I ever be normal again?
Cognition: memory intact; Oriented to person, place and time
Knowledge: appropriate for educational level
Endings: Denies
Reliability: good
MMSE
Glascow Coma Score
Physical Exam in ICU:
Vitals:
General: AAF, heavily sedated, on mechanical ventilation
HEENT: NC/AT; Pupils are 3mm each; equally rounded and reactive to light, + cornel
reflex, no discharges from ears or nose
Neck: Supple, no thyromegaly appreciated
Lungs: CTA bilaterally, no wheezes or rales
CVS: normal s1/s2, no murmurs, rubs, or gallops
Abdomen: soft, obese, non-tender, bowel sounds present
Extremities: no edema on bilateral lower extremities. Patient has bilateral chronic
skin changes. Dark pigmented spots in LE. Right foot has diabetic foot ulcer with
purulent drainage. Left foot has 4th toe amputation
Labs (Admission 2/2/2016)
CBC
WBC 6.5
RBC 4.4
H&H 8.6/29.2
MCV 87.4
Platelets 205
PT/INR/PTT 101/0.9/32/8
General Chemistry
Na 139
K 4.2
Bicarb 25
Cl 105

Creat 0.6
BUN 26
Calcium 8.7
Glucose 202
GFR >60
Mag 1.5
LFT
TP 6.3
Albumin 3.1
Tbili 1.2
ALT/AST 19/21
Alkphos 103
GGT 27
Acid/Base
pH 7.41, HCO3 20.3, CO2 32.8, pO2 67.9
Lactate 1.1
Ammonia 52
Hemoglobin a1c 10.7
TSH: 0.241
Free T4 1.43
Alcohol screen: <10
Urine Drug Screen: + Benzodiazepine
U/A: clear, 1.01 sg, 6.5pH, neg proteins, >1000 glucose, neg ketones, billirubin or
blood, + nitrites, small leukocytes, few bacteria, 5-10WBC, few epithelial cells
Imaging 2/2/2016
Chest Xray with bilateral infiltrates
Head CT w/o contrast neg
Echocardiogram Normal EF. Estimated peak pressure 45mmHg to 55m, HG
RPR Non Reactive
Sputum Culture (2/6/2015) numerous WBC, few gram +, SERRATIA MARSCECEANS
Admission Medications (2/2/2016)
Current Medications (2/8/2016)
Klonopin 2mg oral BID
Docusate sodium 100mg oral TID
Enoxaparin 40mg subq Q24h
Esomeprazole 40mg oral QAM AC
Folic acid 1mg per NG tube daily
Influenza vaccine 0.5mL IM once
Insulin glargine 20U subq HS
Insulin lispro 1-12 units subq correctional sliding scale
Lactulose 30mg oral daily
Nifedipine 60mg oral daily
NaCl 10mL IV once PRN and perflutren lipid microsphere 2mL IV once PRN
Quetiapine 300mg oral BID

Quinapril 20mg oral daily


Setraline 100mg oral daily
Sitagliptin 50mg oral daily

Continuous infusion 0.9% NaCl 84ml/hr


PRN meds: acetaminophen
Assessment:
SP is a 52yo AAF, single, domiciled, with a PPH of bipolar 1 disorder, depressed type
and PMH of HTN, Hypothyroidism, and T2DM. She was BIB EMS 2/2 being found
unresponsive by family member, found to be hypoglycemic by EMS with finger stick
of 24mg/dl, s/p dextrose and narcan, was intubated thereafter for airway protection,
heavily sedated due to agitation, and admitted to MICU for sedation break and
weaning off ventilator. Patient was successful extubated on 2/6/2016 and
transferred to 10CHC.
1.) Altered Mental Status, Unspecified
-most likely due to hypoglycemia 2/2 to medication overdose (patient takes glipizide
5mg BID) vs ? pneumonia
- patient has recent a1c of 10.7 and will need insulin as home regimen
2.) Type 2 Diabetes Mellitus
- patient has recent a1c of 10.7 and will need insulin as home regimen
-continue to monitor finger sticks POCT
-needs dietary evaluation and diabetic teaching
-endocrinology follow up
3.) Hypertension
-stable
-continue meds
4.) Bipolar 1 Disorder, depressed type
-continue current management as per primary team
-patient is not suicidal, homical, or have psychosis at point of evaluation (2/8/2015).
At this point patient is not in danger to self or others and there is no psychiatric
need for C:O 1:1
-patient does not need an acute psychiatric intervention at this time
-patient was educated on compliance with medication and follow up appointment
with Dr.Pierre Paul on 12CHC
-patient may resume psychiatric meds including quetiapine 300mg oral BID and
setraline 100mg oral daily
-patient is psychiatrically cleared for medical disposition