DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
CHIEF COMPLAINT: Metabolic encephalopathy.
BRIEF HISTORY: The patient is a (XX)-year-old gentleman with a history of acute alcohol intoxication. He drank a whole bottle of whiskey and was brought to the emergency room in a semiconscious state, lethargic, and somnolent.
PHYSICAL EXAMINATION: The patient’s vital signs revealed a blood pressure of 96/42, pulse 122, respirations 18, and temperature 98 degrees. His pupils were reactive and disks were flat. Sclerae were clear. The oral mucosa was dry. Posterior pharynx was without thrush. Tympanic membranes were without lesion. The neck was supple. No jugular venous distention, carotid bruits or cervical adenopathy. Lungs revealed bilateral rhonchi. Cardiovascular examination showed normal S1 and S2. Gastrointestinal examination revealed that the bowel sounds were present with no guarding or masses in the abdomen. Examination of the extremities revealed no edema, clubbing or cyanosis. The pulses were 1+. On neurologic examination, the patient was lethargic but able to answer questions. Motor and sensory were intact.
HOSPITAL COURSE: The patient was admitted with cocaine and alcohol abuse, also noted to have diabetes. He was started on normal saline at 125 mL an hour, sliding insulin scale, and his clinical status was followed. The patient was detoxed without complication. He had no seizures. Ativan 1 mg q. 8 hours was added to his regimen. He was given a 2-gram magnesium bolus for hypomagnesemia. He was started on thiamine 100 mg daily and seen in consultation by Dr. John Doe, who recommended Librium 25 mg q. 8 hours for 2 days and 25 mg b.i.d. for 4 doses.
The patient also had some back pain and was started on Percocet 1 tablet q. 4 hours p.r.n. He has a history of a fracture to right patella and was evaluated by Dr. Jane Doe, who recommended we continue with conservative management. The patient was offered the chance of going to a rehab program to address his substance abuse. The patient refused this option.
By MM/DD/YYYY, he had been fully detoxed. He was alert, oriented, and ambulatory. The patient was stable for discharge. He was discharged to home in good condition, guarded prognosis because of the substance abuse. He was discharged on a regimen, which included Lantus 30 units daily, Bextra 20 mg daily, Nexium 40 mg daily, and Lopressor 50 mg daily. He will follow up in the clinic in 1 week.
LABORATORY DATA: Hemoglobin 13.6, hematocrit 41.2, white blood cell count 5100, and platelet count 272,000. Sodium 141, potassium 4.2, chloride 100, CO2 of 30, BUN 13, creatinine 0.8, and glucose 202, protein 8.2, albumin 4.2, calcium 8.8, and bilirubin 0.34. AST 19, ALT 36, alkaline phosphate 210, CK 134, magnesium 2.6, troponin is 0, vitamin B12 of 376, folic acid 9.2, pH 7.3, pCO2 42, pO2 132, and bicarbonate 36.
CT of the brain showed no evidence of a bleed. Chest x-ray showed no infiltrate. EKG showed normal sinus rhythm with no acute ischemia.
DISCHARGE DIAGNOSES:
1. Alcohol abuse.
2. Cocaine abuse.
3. Diabetes.
4. Tachycardia.
5. Fracture of the right distal tibial plateau.
