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

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