kviolet
Networker
HPI
Chief Complaint
Patient presents with
• Drug Overdose
20s y.o. F now presents for unknown ingestion. Pt with ingestion of ?cocaine/PCP (reportedly never heroin user) per EMS. Bystanders have 8mg IN naloxone, NYPD gave 4mg IN naloxone. She had no response to naloxone administration per EMS. Pt here states that she is cold and is oppositional towards hospital staff.
Patient History
No past medical history on file.
No past surgical history on file.
No family history on file.
Review of Systems
Review of Systems
Unable to perform ROS: Mental status change
Physical Exam
Vitals:
05/02/22 1818
BP: 91/79
Pulse: 105
Resp: 26
SpO2: 93%
Physical Exam
Vitals and nursing note reviewed.
Constitutional:
Appearance: Normal appearance.
HENT:
Head: Normocephalic and atraumatic.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Abdominal:
General: There is no distension.
Tenderness: There is no abdominal tenderness.
Neurological:
Mental Status: Unknown Af Newmexico is alert.
Comments: Pt rousable to voice and answers questions but is otherwise oppositional; MAE
Medical Decision Making
Assessment/Plan
Number of Diagnoses or Management Options
Altered mental status, unspecified altered mental status type
AMS (altered mental status)
Cardiac complaint
Diagnosis management comments: 20s y.o. F now presents for unknown ingestion. Exam as above. Concern for accidental ingestion. Will obtain labs as ordered. Pt received 1g naloxone IV on examination without effect. MAP 62 at this time as pt sleeping on stretcher. Plan to allow patient to metabolize ingestion. Dispo pending findings / return to baseline mental status.
Amount and/or Complexity of Data Reviewed
Clinical lab tests: reviewed
Interpreter Services: Not Applicable - Interpreter Services not required
Critical Care Time
Yes: Critical Care Time
I spent 45 minutes of Critical Care Time (excluding separately billable procedures) involving high complexity decision making to assess, manipulate and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of patient's condition.
CRITICAL CARE
I am concerned for critical illness acutely impairing at least one organ system with a high probability of imminent or life-threatening deterioration in patient condition.
Organ systems include cardiovascular, metabolic, and respiratory . The following time-sensitive emergent care interventions were initiated to prevent sudden, clinically significant deterioration: attempting to obtain collateral information/reviewing prior EMRs, bedside reassessment, continuous cardiac monitoring, expedited laboratory tests and radiological imaging, immediate bedside evaluation and management, and reviewing test results.
Electronically signed by t 5/2/2022 6:40 PM
ED to Hosp-Admission (Discharged) on 5/2/2022
ED to Hosp-Admission (Discharged) on 5/2/2022
Note shared with patient
Care Timeline
05/03 Admitted from ED 0735
Discharged 1506
Patient signed out to me for reassessment, follow-up of CT head, and likely admission to hospital for evaluation.
Patient obtained CT head, appears grossly unremarkable. Discussed with patient, is now sober appearing, states she cannot recall what happened prior to arrival but was smoking at a friend's house and then started having vomiting and passed out. Was using PCP per patient. At this time patient concerned about lapse of mental status. Removed oxygen from patient, on monitor had hypoxia to 87% on RA. Possible narcan-induced pulmonary edema given received several mg of narcan, given hypoxia and altered mental status would still need admission to hospital for monitoring and treatment.
ED Nursing Note
Pt arouse able to verbal stimuli, pt remains on monitor with supp O2, when asked what substance pt ingested, pt states "I don't know".
Chief Complaint
Patient presents with
• Drug Overdose
20s y.o. F now presents for unknown ingestion. Pt with ingestion of ?cocaine/PCP (reportedly never heroin user) per EMS. Bystanders have 8mg IN naloxone, NYPD gave 4mg IN naloxone. She had no response to naloxone administration per EMS. Pt here states that she is cold and is oppositional towards hospital staff.
Patient History
No past medical history on file.
No past surgical history on file.
No family history on file.
Review of Systems
Review of Systems
Unable to perform ROS: Mental status change
Physical Exam
Vitals:
05/02/22 1818
BP: 91/79
Pulse: 105
Resp: 26
SpO2: 93%
Physical Exam
Vitals and nursing note reviewed.
Constitutional:
Appearance: Normal appearance.
HENT:
Head: Normocephalic and atraumatic.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Abdominal:
General: There is no distension.
Tenderness: There is no abdominal tenderness.
Neurological:
Mental Status: Unknown Af Newmexico is alert.
Comments: Pt rousable to voice and answers questions but is otherwise oppositional; MAE
Medical Decision Making
Assessment/Plan
Number of Diagnoses or Management Options
Altered mental status, unspecified altered mental status type
AMS (altered mental status)
Cardiac complaint
Diagnosis management comments: 20s y.o. F now presents for unknown ingestion. Exam as above. Concern for accidental ingestion. Will obtain labs as ordered. Pt received 1g naloxone IV on examination without effect. MAP 62 at this time as pt sleeping on stretcher. Plan to allow patient to metabolize ingestion. Dispo pending findings / return to baseline mental status.
Amount and/or Complexity of Data Reviewed
Clinical lab tests: reviewed
Interpreter Services: Not Applicable - Interpreter Services not required
Critical Care Time
Yes: Critical Care Time
I spent 45 minutes of Critical Care Time (excluding separately billable procedures) involving high complexity decision making to assess, manipulate and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of patient's condition.
CRITICAL CARE
I am concerned for critical illness acutely impairing at least one organ system with a high probability of imminent or life-threatening deterioration in patient condition.
Organ systems include cardiovascular, metabolic, and respiratory . The following time-sensitive emergent care interventions were initiated to prevent sudden, clinically significant deterioration: attempting to obtain collateral information/reviewing prior EMRs, bedside reassessment, continuous cardiac monitoring, expedited laboratory tests and radiological imaging, immediate bedside evaluation and management, and reviewing test results.
Electronically signed by t 5/2/2022 6:40 PM
ED to Hosp-Admission (Discharged) on 5/2/2022
ED to Hosp-Admission (Discharged) on 5/2/2022
Note shared with patient
Care Timeline
05/03 Admitted from ED 0735
Discharged 1506
Patient signed out to me for reassessment, follow-up of CT head, and likely admission to hospital for evaluation.
Patient obtained CT head, appears grossly unremarkable. Discussed with patient, is now sober appearing, states she cannot recall what happened prior to arrival but was smoking at a friend's house and then started having vomiting and passed out. Was using PCP per patient. At this time patient concerned about lapse of mental status. Removed oxygen from patient, on monitor had hypoxia to 87% on RA. Possible narcan-induced pulmonary edema given received several mg of narcan, given hypoxia and altered mental status would still need admission to hospital for monitoring and treatment.
ED Nursing Note
Pt arouse able to verbal stimuli, pt remains on monitor with supp O2, when asked what substance pt ingested, pt states "I don't know".