Respiratory failure

Emergency Department

Patient Case Number: ED31-Wright, Troy

Patient Name: Troy Wright

DOB: 06-16-74

Sex: M

Date of Service: 09-19-XX

Attending Physician: Noel Roberts, MD

Reason for Visit: Respiratory failure

History of Present Illness:

The patient was awake and alert when he came to ER. He then passed out and was intubated due to respiratory failure. Pt was on a Diprivan drip, but extubated himself this morning. He is now doing ok, alert, awake, responding appropriately. He denies any complaints. The patient overdosed on whatever meds he had at home. Metformin and Gabapentin being some of them. He denies any suicidal thoughts, but says the meds make him depressed.

Medications:

Astelin 137 mcg/inh nasal spray, 2 spray(s), Nasal, BID Atorvastatin 20 mg oral tablet, 20 mg/ 1 tab(s), Oral, Daily Gabapentin 600 mg oral tablet, 1200 mg/ 2 tab(s), Oral, 11D Hydrochlorothiazide 25 mg oral tablet, 25 mg/ 1 tab(s), Oral, Daily Januvia, 25 mg, Oral, Daily

Metformin, 500 mg, Oral, BID

Prednisone 10 mg oral tablet, 10 mg/ 1 lab(s), Oral, Daily

Allergy: Beta blockers

Review of Systems:

Constitutional: No fever, No chills, No sweats, No weakness, No fatigue, No decreased activity.

Respiratory: Some cough, no phlegm, no sob,

Cardiovascular No chest pain, No palpitations, No bradycardia, No tachycardia, No peripheral edema, No syncope.

Gastrointestinal: No nausea, No vomiting, No diarrhea, No constipation, No heartburn, No abdominal pain.

Neurologic: Alert and oriented x 4, No abnormal balance, No headache

Vitals:

Temperature

99.0°F

Pulse

108

Respirations

16

Blood Pressure

130/80

SpO2

94%

Weight

308lbs

Physical Examination:

Constitutional: awake, alert, oriented to time/place/person, morbidly obese

HEENT: unremarkable

CHEST: clear except reduced breath sounds bases

HEART: distant, but regular

Assessment/Plan:

Intentional ingestion – overdose psych consult, stat

Metabolic acidosis, from Metformin and Gabapentin.

Respiratory failure 2/2 overdose

DM on Metformin and Januvia. Will start sliding scale insulin

Htn- was on hctz, currently on hold

OSA, hasn’t used CPAP for the last 5 years

Morbid obesity

Diabetic Neuropathy – on Gabapentin

Hyperlipidemia on Lipitor monitor labs.

Electronically Signed By: Noel Roberts, MD