Doctors’ Notes

A Death in the Hospital /Doctors’ Notes

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Page 1/37

CURRENT MEDICATIONS:>Amitriptyline(Elavil) 40milligrams(mg) Past Medical History (PMH): +Psych(iatric) (?)”mild hypertension (HTN)> diet controlled Negative (-) Diabetes Mellitus (DM) “Panic Attacks” Assessment: presents (as) alert and oriented X3 (+) nausea and vomited in ambulance—

ASSESSMENT: presents Alert and Oriented X3 +nausea>vomited in ambulance-full Range of Motion (ROM)-denies abdominal pains presently but claims “heartburn” before arrival +dizziness and headache _ presents with IV (in) Left Arm begun by Emergency Medical Service (EMS) (60 cc infused in field)-states, “I feel much better now.” D. Peterson, R.N. *multiple abrasions noted to face, nose, cheek and temporal area 5PM Patient is a 23 year old white male brought in by EMS following a syncopal episode. Patient was recently placed on Elavil by outside Psychiatrist to begin at 10mg QD (once a day) and to increase QID (4X/day) by 10mg > Patient had just graduated to 60mg QD (once a day) and last pm developed lightheadedness when standing – father gave patient 1 dose of 25 mg of Bethanechol – Today patient felt “jittery and walked over to window with his sister when (?) he became pale lightheaded and fell to ground on his face sustaining abrasions – patient was “shaking like a fish out of water” according to sister for about a minute then was unconscious X 10 minutes more patient awoke confused> +disoriented EMS called and transported patient to ER – Patient remembers none of these events>sister was witness

Patient remembers none of these events>sister was witness Patient denies Chest Pain (CP), Shortness of Breath (SOB) – “just jittery” denies taking increased medication, denies suicidal or homicidal ideation (cont’d) Kevin (Hewitt)?

Page 2/37

8/21/97 Attending ER (continued)

Patient took only (the) medications prescribed as told except for the Bethanechol that father gave him (father is M.D.-psychiatrist for possible constipation with Elavil) Nausea/Vomiting (?) on arrival – none thereafter -Headache +abrasions on face -neck pain -double or blurry vision NKA (told to avoid Immodium) -Shortness of Breath -paresthesias or motor weakness

Physical Exam: NAD(? No Acute Distress) abrasions to nose cheeks and chin (?) Pupils Equal and Reactive to Light (perla), (?)fundi sharp (?)-(?) Nose abrasions on bridge NT – deformity -abrasions on cheeks and chin (?)bilaterally no point tenderness tongue midline moist mucosa (?) Neck supple NT Full Range of Motion

Neck supple NT(?) Free Range of Motion (FROM)
Chest clear to Auscultation and Percussion (A&P)
COR (heart) Regular Sinus Rhythm (RRR) SV2 (?)
Abd(omen) soft NT (?) +Bowel Sounds (BS)
EXT (?external) no c/c/e
Neuro: Alert and Oriented X3
Cranial Nerves (CN) I-X11 intact
Motor 5/5 (?) bilateral
Sensory + (?)
Deep Tendon Reflexes (DTR) 3+bil(ateral)
Plantar Reflexes Down (a normal finding)
EKG: #1 SR/98/53/PR 0.156/QRS – 0.112/no ST-T changes
#2 (post-NaHCO3): ST/111/71/PR 0.188/QRS 0.104/
no ST-T (changes)

8/21/93 MAR (?)
Admit to telemetry S(tatus)/P(ost) seizure
on Elavil
intern Berkowitz 7089
Resident (?)
ATT(ending) Goodman Ward

Page 3/37

8/21/93 MAR IMSR (?) Admit
23 y(ear) o(ld) w(hite) male with h(istory)\o(f) Crohn’s Disease (age 16-19) currently in remission, also with h(istory)\o(f) Panic attacks x (for) 2 years with signs of depression. Recently started on Elavil 2 weeks ago with incremental doses (now on 60 mg qd-once a day). Patient has noted some signs of orthostatic hypotension x (for) last 2 d(ays) with decreased appetite, but has been otherwise well. Today was noted to have witnessed LOC (loss of consciousness) persisting approximately 10 minutes post event – no mention of fecal, urinary incontinence but patient with multiple abrasions over face. Denies suicide attempt or excess ingestion med (medications) Elavil 60 (mg) qd (once a day)

P(hysical)/E(xam) B(lood)P(ressure) 160/80 P(ulse) 110
R(espirations) 16 tahb (?) neg orthostat (?)
HEENT (head, eyes, ears, nose, throat) PERLA (pupils equal reactive to light)
EOMI (?) neck supple oroh (?) clear
no nodes multiple facial abrasions
CVS S1S2 (?)
lungs cta (clear to auscultation)
abd(ominal)B(owel)S(ounds) normal soft NT (?) ND(?) -HSM(?)
ext(ernal) ? 2+pulse (?)
CNS (Central Nervous system) WNL (within normal limits)
AxOx3 (completely alert and oriented) pleasant white male nonfocal
no meningitis signs.
labs: 17.7>———–>253 S7 101>84
44.3 89 4.1 1.2
Calcium-Magnesium (P) 12.9/11.7

Impression————-likely seizure ingesting of new elavil
loading. Doubt excessive ingestion
No serious trauma
Slight widening of QRS but no other arrhythmia’s
Will admit to telemetry. Patient given HCO3 (bicarbonate) +
dilantin load. Amitryptylline level sent.

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(a section of the EKG strip is presented here – see image)

5:30 P(M) orthostatics: O——->130/80 P(ulse)-96 (B/P)150/90 P-106
Patient received a+ox3 (completely alert and oriented) –
full R.Om (range of movements) – undigested food noted
on clothing + emesis basin – 12 lead EKG done
STACH (?) HR(heart rate) 106, M.D. aware—-.see above
monitor strip Presents with R/L #1 W/O (?) finished – now #2
R/L KVO (?) – Pulse of 96 (Radial Artery) side rails up – Status Post
“passing out” can’t recall incident–>EMS called by sister who
witnessed incident, denies chest pain, +pulses, pending
M.D. evaluation————————->D. Peterson, R.N.

7p(m) Seen by Dr. Hewitt, cbc, chem(istries)7, PtPh(?), SMAC20 +
STAT elavil level sent to lab–>transported to CT scan (by?) house M.D.
on port(able) cardiac monitor H(eart)R(ate) 120 – B/P 150/70
R(espirations)-20, denies any pain or discomfort – D. Peterson (R.N.)
7:30p(m)-Back from XR(ay)-had head CT(scan) done-attached(?) to
wall PM(?) – N(ormal)S(inus)R(hythm) in no acute distress –
Labs as follows:
137 101 14 15.1
——————-<84 17.7(?) 253 ? 21 1.2 4.98 44.3 CT of head (pre) - negative Hct (?)< 15.1 7:55p - EKG to be done #2 - (illegible name) RN 8P(M)- EKG done and read by Dr. Hewitt - (illegible name) RN 9:05p BP-140/90 p(ulse)-102 R(espirations)20 MAR(medical admitting resident(?) in and evaluated patient - for A(dmission?) (?) - Dilantin ? /N(ormal)S(aline) 100cc to run over 30 minutes via IVAC pump pt(patient) continuously on cardiac monitor for monitoring 9:45 p(m) - patient for admission - (illegible name) 9 (?) --to go to 2 RE (river east) - (illegible name) - awaiting transport

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8/21/93 MIA (Medical Intern Admission Note?)

Informant: Patient
CC (Chief Complaint) – I fell
HPI (History of Present Illness) – This is the first CPMC (Columbia Presbyterian Medical Center) admission for this 23 year old recent college graduate with psychiatric history significant for Panic attacks + the suggestion of recent Depression started on Elavil 2 weeks ago. The patient whose psychiatric care is managed by his father began to take Amitriptyline 2 weeks ago. The patient was in his USOGH (Usual State of Good Health) until 2 days PTA (Prior to Admission) when he noticed symptoms of orthostatic hypotension. He never lost balance or consciousness. On the morning of admission he arose early (3AM) and was not feeling himself. He also experienced a small panic attack. While alone with his 10 year old sister this morning, the patient fell from a standing position and began to write like a fish out of water according to the girl. The LOC (Loss of Consciousness) lasted 10 (minutes) and was not associated with fecal or urinary incontinence. The patient was confused by the time EMS arrived but A&OX3 (Alert and Oriented) upon arrival in the E.R.

The patient denies drug abuse, O/D (Over Dose) attempt, suicidal or homicidal ideation – he had a normal EEG 1 – years ago.
Past Medical History Crohn’s Disease – now in remission, bloody stools from 16 – 19 with + (positive) colonoscopy
PSH x negative (?)
Allergies ?Immodium
PE (Physical Examination) 160/80, P(ulse) 110, R(espirations) 16 (lying down)
170/90, P(ulse) 110 (Standing)

PE (Physical Examination continued)
Well developed WN (Well Nourished) young man looking his stated age, lying nervously in his
stretcher in the ER, he had hypotension but talked clearly
the head erythematous contusions covered with Vaseline diffusely across the face.
HEENT (Head, Ears, Eyes, Nose, Throat) – Pupils ERRLA (Equal and Reactive to Light),
neck supple, negative nodes, negative JVD (Jugular Venous Distension).
Lungs – CTA (Clear to Auscultation)
CV – RR n/s1s2 (?)
Abd(omen) + BS (Bowel Sounds), – HSM(?) SNTND(?)
Ext(ernal) +pulses Equal
Neuro (Neurological Examination): A&OX3 (alert and oriented)
nonfocal (?) exam
CXR (Chest X-ray)
ECT ST 100-110 (?heart rate), PR (PR interval) .16/.11 QRS widening

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(8/21/93 note of Intern in Emergency Room, continued)
Labs ASA(aspirin) neg 12.9
Ca(lcium) 9.4 26.2 17.7>–<253 137---101---14<84 Mg(nesium) 2.0 44 89 4.1 21 1.2 Imp(ression) Elavil toxicity in a 23 year old male on elavil for approximately 2 weeks Neuro-characteristic seizure activity based on description following elavil vsc(?vascular) Levels, pending. The prolongation of the QRS is consistent with amitriptylene toxicity (?)AMP(?ampule) HCO3 (bicarbonate) to protect heart Tox(icology)-Denies suicide attempt but ASA(aspirin), Tylenol X(within normal limits) Urine for toxicology sent CV(cardiovascular)-Wide QRS treated with HCO3 Follow on telemetry / (initials-Noah Berkowitz) 7089 8/22/93 Attending 23 year old male with history of Anxiety Depression, started on Tricyclic ~(approximately) 2 weeks Ago. S/P (status post) Generalized Seizure yesterday, getting contusions to Face, Exam(ination) otherwise unremarkable. EKG shows QRS>10
(?) CT (scan) Negative
New onset Seizure ? due to Amitriptylene vs(versus) New onset seizure Disorder
(vs head trauma, less likely). Patient to be monitored X (for) 24 hours;
Neurology to See.
R. Goodman

8/22/93 IPN(?) (Only Intern Berkowitz note on Sunday, day after admission)
Patient doing well
Neg Complaint Of, (?),CP(Chest Pain), palpitations dizziness N(nausea?Vomiting)
H(eart)R(ate) 100-110, (?) vss(?) afebrile
C(ardio)V(ascular) – unchanged.

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(continuation of Intern Berkowitz note of Sunday, 8/22/93)
Lungs CTA(Clear to Auscultation)
Abd(omen) +B(owel)S(ounds) SNVD(?)
Neuro A&OX3 (Alert and Oriented
Non focal
Imp(ression): S(tatus)P(ost) seizure + Elavil toxicity
Neuro – awaiting neuro consult
C(ardio)Vascular) – On telemetry (?) last night
Tox(icology) – As A (Aspirin is negative), urine toxicology pending
WBC – probably post ictal (?)
/(Noah Berkowitz initials) 7089
8/22/93 Intern Add(ition)
H(ome #) 718-601-7208
Office 212-988-4800
/(Noah Berkowitz initials) 7089

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8/22/93 Neurology
23 year old recent college graduate in remission from Crohn’s disease (had onset of anxiety – panic attacks several years ago – when Crohn’s became quiescent). Uses Ativan/Valium intermittently – he says “none since May” – father says “still in use.” Long history tremor (like his father).
Started on Amitriptyline 2 weeks ago – as dose was raised to 60 mg qhs (ie, at bedtime) he had symptomatic orthostasis (i.e., hypotension). Yesterday, while standing from sitting position, he had a G(rand)M(al) seizure with facial abrasions as result.

Page 8/37

continuation of evaluation of Dr. Sagman, Sunday, 8/22/93)
Father says he is sli(ghtly) confused or “slower” this P.M. than he was this morning.
1. diffident, hesitant speech – facial abrasions – tongue unbitten
2. Fundus – negative
3. active tremor
4. significant H(?and) – K(nee) tremulousness
5. BP 160/80 supine
130/80 standing

1. Drug – induced orthostatic hypotension
2. Convulsive syncope
3. Benign Familial Essential
4. Modified (benzodiazepine) withdrawal state

Rec (ommendation):
1. EEG
2. Supplementary diazepam now (for protection)
3. Psych consult
4. MRI head if subsequent exams suggest cognitive decline.

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REQUEST FOR: Psychiatry
TO DR.: Collins
DATE: 8/23/93 (Monday morning)

REASON FOR CONSULTATION AND BRIEF HISTORY/PERTINENT LAB DATA: Asked to evaluate this 23 year old single Jewish white male with history of panic disorder /?depression, living with his parents and 10 year old sister, admitted with generalized tonic-clonic seizure and ? Elavil toxicity for suicidality, ?depression, panic disorder. The patient has had panic disorder with daily panic attacks with symptoms (of increased) sweating, anxiety, fear of death. Client, since last December (’92), treated by his father (a psychiatrist), with Xanax up to 4 mg. daily until last May (’93), when he was tapered (*see below). He was seen by a Dr. Quen (?spelling) approximately 2 weeks ago and prescribed Elavil which has been increased to 60mg once a day as of 8/21/93 —->when he developed orthostatic symptoms, fell, hit his head and had tonic-clonic seizures (?had seizure after hitting his head). Patient admits to slight decrease (in) mood, decreased energy, (no) crying spells over the last 6-8 months, with early morning awakening, decreased appetite (0 weight loss), no anhedonia – (?denies) suicidality – father states patient only wants to live because of his 10 year old sister – patient states that pat(ernal) gf (grandfather) committed suicide, father denies this; patient denies xanax since May father states patient has been taking Xanax in past week – 2 weeks. Father found bottle of Serpasil (reserpine) which patient had forged with father’s signature. Father reports patient drank a bottle of gin last week – patient denies ETOH (Alcohol)/drugs

MSE (Mental Status Examination): (?)orient(ed), (?)single young white male, making eye contact, with normal speech, with slight tremors, an episode of disorientation – he wondered if we were still in his room or another hospital room, with circumstantial/tangential thought, slight depressed mood, occasionally bizarre affect, denies (?auditory) hallucinations, denies suicidality, denies homicidality – there is some evidence of paranoia – that his father would lie about his symptoms, but no overt delusions (except that his father’s father died due to suicide). Oriented to Monday, 8/22/93, Allen (Pavilion) – 124th Street/Broadway, (?). recalls 3/3 after 5 minutes, spells World (correctly forwards and reverse), (serial seven subtractions), 100, 93, 85, 72 (?unable to continue), knows Presidents to Eisenhower, similarities – apple/orange with fruit, car/airplane with vehicle.

Impression: Complicated clinical picture – with discrepancies in history from son (patient) and
father who was treating patient—>Diagnosis:
1. Panic disorder (?) without agoraphobia
2. Rule Out major depression 3. Rule Out Xanax
dependence with Xanax withdrawal Rule Out Post-concussive syndrome 4. Rule out
atypical psychosis – 5. Rule Out mixed personality disorder I think his suicide risk is low and
does not merit a 1:1 (observation).

Recommend: Hold at(ivan) while some of these issues are clarified—>observe for
benzodiazepine withdrawal (follow BP)
I will explore possibility of psych(iatry) admission electively
Hold Ativan for now
8/23/93 E(ric) Collins, M.D.

Page 10/37

8/23/93 Addendum
1:30PM Patient found wandering hallways – on 2FW – looking in other patient’s rooms. When I saw him – I accidentally ran into him – he told me little children were tormenting him – he was looking for them. Then, when I returned him to his room, he began searching in bathroom, behind door, saying that they were in his room or another next door – as soon as he looks – they will know a secret passage between (?)these rooms. He believes one of them is hiding behind a non smoking sign in his room. He said the children were giving him dolls whose appendages come off.

IMP(ression) Paranoia – with visual hallucinations
Suggest benzodiazepine withdrawal (vs post concussion syndrome doubt)
Will start Ativan – 2mg q(every) 4 hours
1:1 attendant x24 hours
Will arrange for psych(iatric) admission
E. Collins

8/23/93 Nutrition: 2:15PM
Current Diet: Regular 8/21
Chart screened to identify if patient is at nutritional
risk. Patient interviewed. Food preferences taken
Deferred obtaining diet history. Patient will be provided
with routine nutrition care. Will follow up as necessary.

Intern Berkowitz Note
Psychiatry consult appreciated
Patient doing well ?(negative) complaints of chronic dizziness, Nausea or Vomiting
Physical Exam unchanged
Imp(ression) Unclear but complicated history

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(continuation of Intern Berkowitz note of 8/23/93)

with possible recent suicidal gesture but not acutely suicidal
Potential benzo(diazepine) withdrawal
1. Psychiatric follow up and possible transfer to (Psychiatry ward)
2. Ativan taper
3. No seizure (?work up) at this time.
Intern Berkowitz initials #7089

Just noticed the above Psychiatric addendum
Recommend 24 hour 1 to 1
Ativan Q (every) 6 (hours) as recommended
Intern Berkowitz initials 7089

24 August 93
CTSP (called to see patient) for bizarre behavior
RN (Registered Nurse)/1:1 (attendant) unable to control
Patient delusional
(?follow-up) with Psychiatry coverage
Rec(ommend): Haldol 5mg IM
Cogentin 1mg. po
(signature of covering night intern
Dr. Beverly Ortiz)
Click here for image
Click here for previous page

(no further physician examination following placement of restraints until next evaluation note)

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8/24/93 Psychiatry
9:30AM Patient continues to demonstrate evidence of delirium – he believes variously on several different interviews that he is in the Grand Canyon, in Hunter College in a research project, in French class. He was oriented to 10/24–>9/24–>8/24/93. He continues to describe “malnourished, small 10 year old girls” who were hiding in bedsprings. They were tormenting him – and only he could see them.

Last night – he reportedly tried to break the window in his room (?suicide attempt?). He was restrained and given Haldol 5mg/Cogentin 1mg.

Dr. Charles has approved his admission to Psychiatry – after his probable withdrawal delirium clears. Patient’s mother reportedly observed patient taking over the counter meds. Impression/(?history) Probable benzodiazepine withdrawal Continue Ativan 2mg q(every) 4 hours Would have a low threshold for physical restraints. Follow Vital Signs closely (every 2 hours) – observe for evidence – of autonomic instability ( now B/P 150/100, Heart Rate 108, Temperature 98 degrees
(Temperature crossed out by Dr. Collins)

May need Intensive Care Unit admission if delirium worsens, as he may need more intensive nursing care. Consider telemetry to monitor Heart Rate (doubt this is necessary). Dr. Bongiovi will be following tomorrow – she will make arrangements for Psychiatry transfer as appropriate
Discussed with Dr Berkowitz, Ms. Kaufman
E. Collins, M.D. #1252

8/24/93 -Neurology (Dr. David Sagman’s note) Patient’s subsequent course: increasing agitation, hallucinations, bizarre ideation, i.e., delirium, all support diagnosis of an abstinence encephalopathy (benzodiazepine in this patient). Even though he is afebrile, I would perform a lumbar

Page 13/37

(Continuation of note of Dr. David Sagman 8/24/93)
puncture (after discussing with patient’s father). What I thought was convulsive syncope, almost certainly was a withdrawal seizure.
D.L. Sagman

8/23/93 Note of Intern Dr. Noah Berkowitz
(incorrect date is listed on his note. Correct date is 8/24/93)
Patient exhibits a waxing & waning delirium. characterized by disorientation & visual and possibly auditory hallucinations. The patient is on Ativan. After discussing the case with Drs. Sagman and Collins, the decision has been made to perform a L(umber)P(uncture) on the patient. Dr. Collins suggested Morphine to control the patient’s current agitation during the procedure This was discussed with the patient’s father who consented to the procedure performed by me transfer note to follow
(Initials of Noah Berkowitz, M.D.) 7089

8/24/93 Psych(iatry) Addendum
12:40 PM Patient’s BP 150/70 (following Morphine Sulphate) 10mg, Heart Rate=120, Temperature 100.5 Degrees. Patient continues delirious with periods of agitation – shaking his legs violently while in restraints. While Xanax withdrawal is the most likely cause of the seizure/delirium, I would recommend that other causes be ruled out. I agree (as above) with the recommendation for Lumbar Puncture. Also – would repeat head CT(scan) – in case (?) his head injury—>subdural bleed.

(continuation of Dr. Collins’ Psych Addendum)
I feel he should be monitored in the Intensive Care Unit. I would hold neuroleptics for management of agitation, as they lower the seizure threshold. Would increase Ativan to 4mg every 3 hours or 2 mg every 2 hours o(r) more – until vital signs (Blood Pressure, Heart Rate) are stable. Patient’s father, Dr. Speken, suggests using Xanax – as Xanax may be peculiar among benzodiazepines in the difficulty we have in tapering people off it. However, we need to prophalax against seizure, and I feel it is safer to give a medication IV or IM (like Ativan). Could use IV Valium (must be pushed slowly). – Will give Ativan IV Push 2 mg. at once
Discussed with Dr. Vogel
Initials of Dr. E. Collins

8/24/93 MAR (?Medical Admitting Resident)
12:45PM Transfer to ICU for direct observation/monitoring/sedation in
setting of acute benzodiazepine withdrawal
(signature unclear)
(? ICU aware)

Page 14/37

8/23/93 (correct date is 8/24/93) Medical Intern Transfer Note
See Medical Intern Admission note of 8/21/93

Briefly, this is a 23 year old male with panic attacks for 2 years who has been treated by his father a psychiatrist with several medications most recently Xanax and amitryptilene. This patient noted symptoms of orthostatic hypotension 2 days Prior to Admission and experienced a witnessed syncopal episode with tonic clonic movements resulting in abrasions on face. He was unconscious for several minutes but reached the ER Alert and Oriented x 3. In the ER he was found to be jittery with a mild tremor, tachycardic to 110 and BP 160/80 non orthostatic. He was afebrile. He was treated presumptively, for Elavil toxicity with 1 ampule of HCO3 as his QRS was .112. He received 1 gm of Dilantin and was transferred in stable condition without psychotic features to Telemetry.

Yesterday, the patient was noted to have the acute onset of visual hallucinations. He was put on 1 to 1 PDA (?observation) and given Ativan 2mg q(every) 4 hours. Additional consultations with Dr. Speken revealed that his son may have been taking Xanax in the past 2 weeks – a fact not disclosed on admission. Over the past 18 hours the patient has experienced a waxing & and waning delirium with visual & possibly auditory hallucinations. This morning he became more diaphoretic, his Heart Rate rose slightly to 120 and his BP has been 160/120. He became febrile to 100.5 degrees and the decision was made to transfer him to the ICU for closer monitoring and IV benzodiazepine treatment until Vital signs stable

Page 15/37

SAR (Senior Admitting Resident) Intensive Care Unit

8/24/93 23 year old male history panic disorder treated by psychiatrist father with Xanax high dose. Apparently was on Xanax taper or discontinued. Patient had seizure 8/21 and admitted. Had negative CT. felt to be syncopal seizure. Patient exhibited bizarre behavior and psychiatry consulted. Patient became psychotic and talking delirious. Further history revealed Xanax and withdrawal suggested. Transferred to ICU for benzodiazepine sedation and monitor (?=) withdrawal (?, tachycardia, diaphoretic).

On exam patient sedated and delirious, restraints BP 150/90 Heart Rate 120-130 Respiration Rate 14 Facial abrasions (?trauma during Seizure) Lungs Clear to Auscultation (CTA) ar1,s1,s2, (illegible)

(?Treatment plan:) Encephalopathy likely secondary (to) withdrawal
– sedate with benzo(diazepine), keep (?BP, pulse, Heart Rate normal)rather over sedate and intubate than undersedate and seizure.
– Rule out other cause(?) metabolic (labs) or infections (do Lumbar Puncture).
(name uncertain, Birch, Berch)

Page 16/37


Chart reviewed, transfer note read and appreciated. Briefly, this is a 23 year old white man with a history of Crohn’s Disease (age 16, recurrence age 19), panic disorder and possible recent depression, admitted 8/21 after “syncopal” episode and seizure (tonic-clonic seizure witnessed by 10 year old sister ) initially thought to be elavil toxicity, now being transferred to the ICU for management of acute benzodiazepine withdrawal. Patient has had panic attack for number of years and was treated with Xanax by his father, a psychiatrist until recently. Patient then began seeing Dr. Quan (?spelling) who prescribed Elavil beginning 2 weeks ago. Patient began an increasing dosing scale of Elavil and was taking 60mg PO QHS on the day of admission. Patient denied benzo(diazepine) use, claimed last dose was May, 1993. Two days prior to admission patient began experiencing dizziness upon standing, and not quite feeling like himself. He was given 25 mg bethanacol when the orthostatic hypotension persisted for a second day. The day of admission patient felt “jittery” and while standing, became pale & lightheaded, fell to the ground and had a grand mal seizure witnessed by his sister (“he was shaking like a fish out of water”). He was disoriented and confused for 10 minutes after the seizure and then brought by EMS to the ER. On presentation to the ER patient was orthostatic (160/80—> 130/80), mildly tachycardic and afebrile. He had a prolonged QRS complex (0.11), and was admitted to telemetry for probable toxicity. Patient had a negative Head CT(scan). While on telemetry patient became disoriented and confused, anxious, and began hallucinating. Patient was hypertensive and tachycardic and diagnosis of benzodiazepine withdrawal despite patient initial denial of benzo(diazepine) ingestion (father states patient did take benzo(diazepines) recently). Because of hallucinations and paranoia patient was placed on 1:1 observation on telemetry by psychiatry, and Ativan 2mg q 4hours was begun. Patient became increasingly agitated and confused until frank delirium. He apparently tried to put his hand through a window 8/23 at night despite 1:1. Patient is now being transferred to the ICU for more intense observation and monitoring.

Past Medical History Crohn’s as above. On no medications. Currently in remission
All(ergies) ?immodium
Meds elavil 60mg QHS at home
Xanax ?
Family positive family history of panic disorder in paternal grand-
History father
Social patient is a recent college graduate who lives at home with
History parents and sister. Father is a practicing psychiatrist.

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(Continuation of Intern Admission Note to ICU 8/24/93)
Physical Exam Patient is a young male with obvious abrasions on his face,
restrained in bed, babbling about a production, with his eyes intermittently
Vitals: Pulse 103 BP 150/70 R20 T 99.5 (PR)
Heent abrasions on nose, cheeks, edges of mouth, PERLA, Unable to
formally test EOM (?eye movements), but appears to move his eyes
in all directions. mouth: throat non-injected no ulcers. no evidence of
tongue biting.
LUNGS clear
Heart s1s2 normal. II/VI sm (sinus murmur) @ apex–>axilla no clicks – no opening
snap. negative q/r
ABD soft, non tender, non distended no guarding no rebound.
no HSM. positive BS
Ext no c/c/e (?). when awake—>tremors of both hands.
NEURO oriented to name only. waxing and waning consciousness –
speech fluent but nonsensical, tangential. acute hallucinations.
responsive to some commands.
Cranial Nerves
II-XII grossly intact as observed. Patient not able to cooperate
with exam.
Motor appears full strength

LABS: ADMISSION 17.7>——<253 137 101 14 <84 10.1 224 .6/.1 31 44.3 4.1 21 1.2 2.7 8.0 93 199 12.2 5.1 25 26 8/22 137 101 8 <101 13.8 3.7 27 1.1 8/23 9.0>——-<218 40.3 Urinalysis negative Head CT negative EKG CXR Impression/ 23 year old white male with history of Crohn's disease, panic attacks and recent (current) depression admitted status post grand mal seizure and feeling jittery, now known to be benzodiazepine withdrawal. 1. Benzodiazepine withdrawal treatment is replacement benzodiazepine and supportive care. Because Xanax is only PO, will cover initial period with Ativan which can be given IV and its entry into circulation is ensured. Patient's delirium puts him at aspiration risk which also makes PO Xanax a suboptimal choice. - Ativan q(every) 2 (hours) 2 mg to treat (High) BP, (High) Heart Rate, agitation Will do Lumbar Puncture emergency to rule out other etiology of change in mental status. Also to (?rule out) blood secondary (to) subdural hematoma secondary (to) head injury from fall (seizure) 2. Seizure no evidence of seizure activity. Seizure secondary to withdrawal. Ativan should prevent further seizures. Nothing by mouth, and seizure precautions however 3. To Psychiatry (ward) when stable. Signature of Laurel Mayer, M.D.

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23 year old with benzodiazepine withdrawal. Delirious
tachycardia, (?illegible) normotensive. Continue titrating dose. Plans reviewed, agree.
(Signature of Dr. ?Bertz/Burch ICU Senior
Admitting Resident)
8/25/93 Intern Dr. Laurel Mayer note
Patient resting comfortably. easily arousable this morning. Remains
delirious. “I’m in the CBS studio in Burbank”
VITALS 160/60 (overnight ?-130/60) P(ulse) 110 R20
T (?max) 99 T(oral) 98 Input/Output 1600/1020
HEART S1S2 normal I/VI Sinus Murmur @ Apex—->axilla
ABD Benign positive Bowel Sounds
EXT Positive diaphoresis, but greatly improved
Mental Status Oriented to person
continues waxing and waning
appears less physically agitated
LABS CSF : culture (?P)
#1 1 WBC, 2 RBC
#4 0 WBC, 1 RBC
protein 27
glucose 91
Impression 23 year old in acute benzodiazepine withdrawal

1. Withdrawal overnight vitals were stable and improved from daytime
Patient received 2 mg Ativan at 7 (pm), 4 mg at 8, 2 mg at 9pm, 6 mg at 10:30
which held him until 6am today. Patient then received 4 mg and is currently as
described above. BP slightly increased this am. Will consider increasing Ativan
to 6mg q 4 (hours) if BP/P remains elevated or/and patient becomes increasingly
LP results negative for blood (subarachnoid bleed) or infection
Continue seizure precautions
Tolerating Ativan. No need to switch to Xanax yet.
Will follow Creatine PhosphoKinase and hydrate to prevent
Signature of Intern Dr. Laurel Mayer, M.D.)

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8:30 AM (8/25/93) Psychiatry Follow Up (coverage for Dr. Collins) Chart reviewed. Patient interviewed. Mr. Speken is a 23 year old Single White Jewish (man) living with his parents who has history of panic disorder treated in past by his father a psychiatrist with Xanax & most recently by another psychiatrist with Elavil who presented 8/21 after Generalized Tonic Clonic Seizure. Felt initially to be secondary (to) Elavil toxicity. Later patient became agitated, disoriented & psychotic (?associated with) delirium which was felt to be due to Benzo(diazepine) withdrawal. On 8/24 he was transferred to ICU for supportive treatment & monitoring as he manifest(ed) Benzodiazepine withdrawal symptoms current mental status examination – pleasant young male lying calmly in bed with hand restraints speech fluent. prosaic somewhat rapid but not pressured. Mood dysphoric – Affect – very labile. Tearful. Denies suicidal/homicidal ideation. Thought content – Denies auditory/ visual hallucinations – somewhat paranoid – Feels the doctors have lied to him (?)here. (He thinks he was to be transferred to Massachusetts) but no overt delusion. Alert & oriented to name. birthdate. Date (8/25/93) but not place (Thinks he’s in Massachusetts) He was reoriented & remembers having had come to Allen Pavilion. (?)A/P Resolving delirium secondary (to) Benzodiazepine withdrawal continue standing Ativan to treat withdrawal symptoms – I would not change back to Xanax as an antidepressant would be a better choice for treatment of this patient’s panic &

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(continuation of note of 8/25/97)
mood symptoms.
– once patient no longer delirious & medically stable will reassess
need for psychiatric admission –
– will continue to follow with you
(Signature of Psychiatric Resident Mary Bongiovi, M.D.)

8/25/93 ICU Attending
Mr. Speken is a 23 year old male with history of Crohn’s disease & Panic attacks. He had been treated with benzodiazepines but was recently treated with Elavil for possible depression. He was admitted Status Post witnessed generalized seizure. He has been treated for presumed Benzodiazepine withdrawal & is now transferred to the ICU for sedation & close monitoring.
Neuro and Psych are following.
CT & LP are negative
Patient now is sedated with stable vital signs. Plan is to continue sedation as per psych with monitoring of Vital Signs, oxygenation and mental status.
(Signature of Attending Deborah Aronson, M.D.)
8/25/93 – Neurology
Best yet – speech clearer – knows this
is a hospital – knows “August ’93” –
denies hallucinations. Back ache secondary (to) prolonged immobilization.
Rec(ommend): start use of bedside chair (in restraints)
David L. Sagman, M.D.

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(date/time illegible) ICU Coverage
23 year old male status post seizure/benzodiazepine withdrawal
now with urinary output = 300 cc over 12 hours
? drug versus rhabdomyolosis
illegible) – uring electrolytes, creatinine
fluid challenge
(?Dr. Bertz/Burch)

8/26/93 Procedure note from 8/24
An emergent LP was performed. Patient unable to give consent Patient was prepped and draped in sterile fashion. Lidocaine was used as anesthesia A 20 gauge spinal needle was inserted on L3 L4 space Clear Cerebral Spinal Fluid was obtained Specimens sent for cell count, protein, glucose and culture No complications. Patient tolerated procedure well.
Laurel Mayer, M.D.

Page 22/37

8/26/93 IPN /Intern Transfer Note
S. Speken is a 23 year old white male with history of Crohn’s Disease as an adolescent – panic disorder with ?recent symptoms of depression who was admitted 8/21 for tonic – clonic seizures (witnessed by 10 year old sister) thought to be secondary to elavil toxicity since patient was on elavil for treatment of depression. He denied BDZ (Benzodiazepine) use originally but Tox(icology) screen revealed both BDZ (Benzodiazepine) & elavil & he was transferred to ICU for management of acute BDZ withdrawal. The patient was being treated by psychiatrist father with Xanax for panic disorder. he then began to see Dr. Quen for psychiatric condition & was given Elavil 60mg QHS 2 days Prior to Admission began feeling lightheaded & dizzy & was given bethanacol by father. He fainted & had seizure with 10 minute postictal period, 2 days after feeling lightheaded.

In ER patient was orthostatic, tachycardic, & afebrile with (?prolonged .1) QRS complex. Admitted to floor with elavil tox(icity). Work/Up head Ct (scan) negative. Patient became disoriented, confused, anxious began hallucinating was Hypertensive & tachycardic & diagnosis of Benzodiazepine withdrawal made. Patient was on 1:1 & Ativan 2 mg q 4 (hours) & still became increasingly agitated with delirium. Then transferred to ICU
Past Medical History – as above
Allergies – Immodium
Meds elavil 60mg QHS at home
Xanax – ?amount
Family History of panic disorder in paternal grandfather
Social History – recent college graduate. lives at home

Physical Exam on admission (? to ICU significant) for facial abrasions after seizure neuro – oriented to name, waxing & waning consciousness speech nonsensical, tangential, positive hallucinations, non focal

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(conclusion of Intern Transfer Note, unsigned, 8/26/93)
Labs (?)significant for WBC – 17.7, nl(?normal) C7, SMAC (with
?CPK 26), negative Urinalysis

During course of hospitalization, patient put on Ativan & required doses up to 14 mg over a 11 hour period. An LP was performed which (was) negative. Eventually Ativan 2mg q 4 hours was all that was needed for light sedation. this AM patient is calm. Negative hallucinations or agitation. Answering questions appropriately & No Acute Distress. He had some decreased urine output which was felt to be secondary to dehydration. ? (?rhabdomyolosis) though CK only (approximately 2400. He was hydrated vigorously & response of kidneys is being followed.

Vital Signs Input/Output (?) 5700/811
Physical Exam – patient lying in bed with 4 point restraints, easily arousable
patient very appropriate
HEENT multiple abrasions on face by mouth &
forehead. hearing normal. PERLA, EOM intact
Heart – RRR, S1S2, OM/g/r (?)
lungs – CTA B
abd – positive bowel sounds, NT, ND, negative masses
extremities – negative edema, C/C
neuro – axox3 (alert and oriented), speech fluent & appropriate, (negative)
hallucinations (?) non focal

Impression 23 year old with panic diagnosis being treated for benzodiazepine withdrawal doing well
Plan – transfer to Psychiatry to work on issue surrounding Benzodiazepine use
Genito-Urinary – follow Urinary Output & fluid status as well as Creatinine – hydrate as needed. If no urinary output or inadequate investigate possible causes of decreased output.

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8/26/93 1PM Psychiatry Follow Up/Transfer Note
Mr. Speken is a 23 year old single white Jewish male living with his parents, (?)recently graduated from college and who has a history of panic disorder since January 91 until recently treated by his father, a psychiatrist with Xanax up to 4 mg every day & (?)now recently with Elavil up to 60 mg every day which was started by the patient’s father. The patient reports a four months of intermittent decreased mood with anhedonia, psychomotor slowing, decreased sleep. Increased appetite decreased concentration, feelings of hopelessness, but no suicidal ideation or plan

The patient was brought to the ER 8/21 by his family after an observed generalized tonic-clonic seizure. The initial impression was Elavil toxicity; a level was sent but the quantity was not sufficient. A Tox(icology) was positive (for) Benzo(diazepine). He was evaluated by both neurology and psychiatry on 8/23. The latter found him slight dysyphoric without suicidal\ homicidal ideation. There was some evidence of paranoia but no overt delusions. No AH/VH(?) Alert & oriented X3 and cognitively intact.

A few hours later the patient was seen by Dr. Collins of Psychiatry to be wandering on the ward other than his own. At that time he was delusional stating little girls (?) were under his bedsprings were “tormenting.” He was somewhat (?agitated) and disoriented.

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(Continuation of Psychiatry Transfer Note)
The impression was delirium ? secondary (to) benzodiazepine withdrawal & he was given Ativan 1 mg Intra Venous Push. the patient was transferred to(?) the ICU for treatment (see medical summary for (additional) information).

On 8/25 he was evaluated by me & found oriented to person & time. More alert & less agitated. His affect was labile with intermittent tears.

Current Mental Status Examination – sl(ightly) obese young man with facial ecchymoses sitting up in bed. Speech fluent, prosaic. mood – sl(ightly) dysphoric Affect full in appearance & range. Denies suicidal/homicidal ideation.

Thoughts goal directed. Thought
content – no delusions No
auditory/visual hallucinations
Alert and Oriented X3
Click here for image
Click here for previous page
A/P (?) status post Delirium likely secondary Benzo(diazepine) withdrawal
stable now on Ativan 2 mg every 4 (hours)
but with persistent depressive
symptoms without suicidal ideation or
-to be transferred to Eye 6 in
AM on 8/27
-in preparation for transfer, please
Xerox this note and medical transfer
note 7 add to voluntary (in
front of chart). Done by Psychiatry Consult
– patient does not require 1:1 (?attendant).
Signature of Mary Bongiovi, M.D.

Page 26/37

8/26/93 ICU Attending
Mr. Speken is sleepy but easily arousable.
BP 160/86 P(ulse) 98
lungs: clear to Percussion & Auscultation
Heart: reg s1s2
Ext: without (unclear abbreviations)
Doing well. Schedule for transfer to Psych in
A.M. Cont(inue) Ativan regimen as per Psych recommendation.
Signature of (Deborah) Aronson, M.D.

8/26/93 ICU coverage att(ending)
23 year old male with history of benzo(diazepine) abuse, presented
with seizures, now stable on ativan taper. Plan discussed with team.
P Gordon, M.D.

Page 27/37

(Transfer summary of Intern Laurel Mayer, 8/27/93. This is noted as a Continuation
Sheet. Part 1. of it with the initial history and treatment is missing.)
S (?) Patient without complaints
O(?) vitals 160/110 2800/2850 90 20
LUNGS Clear EXT no C/C/E.
HEART S1S2, normal em/a/r (?)
ANA (-) 9.0 158 .71.3 39 PT 12.7/11.8 143 110 4 <84 ESR 20 3.7 6.5 80 216 PTT 29.6/29.7 3.7 25 .9 4.4 3.9 59 1011 12.9 8.5>—–<188 34.2 7:36/40/89 97/. creatinine 328 U(rine) Na 207 U k 54 U cl 275 Imp(ression)/ 23 year old white male panic disorder admitted with benzodiazepine withdrawal. now stable - 1. withdrawal patient fully oriented - on 2mg PO ativan every 4 (hours). Doing well. No seizures, delirium or agitation. Transfer psych. 2. CPK (Creatine Phospho Kinase) decreasing. continue PO hydration - Medically cleared Stable for transfer. Laurel Mayer (M.D.) 8/27 ICU Attending Mr. Speken is alert, oriented, and conversant. Blood Pressure and Heart Rate mildly elevated likely secondary anxiety & ? secondary withdrawal. Continue Ativan. Transfer to psych today. (initials of Debra Aronson, M.D.)

Page 28/37

(Initial evaluation on Eye 6 where Seth had been transported by ambulance from Allen Pavilion)


DATE: 8/27/93
IDENTIFYING DATA: 23 year old single white Jewish male who lives home with parents and younger sister, with history Crohn’s disease, panic disorder, & major depression, transferred from Allen ICU after 1 week treatment for seizures x 1.
LEGAL STATUS: voluntary
CHIEF COMPLAINT: “I have panic disorder”
HISTORY OF PRESENT ILLNESS: 23 year old white male, first Psychiatry admit, complains of approximately 2 year history of panic attacks, consisting of increased heart rate, feeling of suffocation, & sweating, often brought on in situations where he feels a task is demanded of him. The first time one occurred, patient felt as if he were having an MI (Myocardial Infarct), & was treated in an ER & told to see a psychiatrist. Patient saw a Psychiatrist MD X4, was prescribed Klonopin 6 mg/day with some relief, but stopped after his father (a Psychiatrist M.D.) said it was too much medicine.

Patient’s father began treating him with Xanax 4mg every day with decreased severity of attacks. Patient reports having the attacks every day, though was able to do well in college, drive, go to movies & vacation. He reports taking Xanax 4mg only on weekdays, not weekends or vacations, & taking some 1-2 months drug holidays during which he did not have panic attacks (and withdrawal signs/symptoms), since he knew how to taper.)

6 months Prior To Admission, in setting of painful rejection from grad school, patient noted to be dysphoric, anhedonic, hypersomnolent, decreased appetite, & feelings of hopelessness, but never Suicidal Ideation. Over ensuing 2 months, patient had increasing guilt over Xanax use–“felt like a drug addict,” “felt cut adrift with no control over my life.” These feelings were reinforced by his father who told him he was taking too much, but continued to prescribe. Patient denies ever getting meds on his own with father’s prescription pad (except Flexeril, years ago, when father away).

4 months Prior to Admission, father tapered him off Xanax & started Zoloft. Patient took 1 (?) month without improvement in mood, & severe agitation. Then restarted Xanax 4mg daily and

Page 29/37


History of Present Illness Continued: experienced worsening guilt/loss of control secondary to Benzodiazepine use—–>decided to totally discontinue Xanax when school finished in 2 months. Also, felt the need to “commit myself,” & get a psychiatrist. Xanax tapered 1 months Prior To Admission, totally discontinued by 15 days Prior to Admission (patient is adamant that he took no Benzodiazepine until admit; father, by report, thinks he did).
2 weeks Prior to Admission, patient seen by Dr. Quen (Psychiatrist M.D.) who prescribed Elavil 10 mg (?with ?mg increases every day)–> (to) 60mg by 8/20. Given Bethanechol 10 (mg) for diarrhea(?).
1 day prior to Allen admit, patient felt dizzy upon rising to a standing position, though did not lose balance or consciousness.
The am of Allen admit, he awoke at 3am, did not feel like himself, & had some panic. Later that am, while alone with his sister he fell from a standing position & was noted by his sister to (cont) be “writhing like a fish.” Loss of consciousness lasted 10 minutes, without urine/fecal incontinence. He was brought to the Allen ER confused & disoriented, with multiple facial abrasions. He denied headache, neck pain, visual changes, paresthesias, motor weakness, shortness of breath, but did complain of some nausea and vomiting. Noted to have widened (.11) QRS (treated with Bicarbonate), WBC 17,7, CT within normal limits, Cerebral Spinal Fluid exam within normal limits, & admitted for presumed Elavil toxicity (level not done). Tox(icology) screen———–>positive for Benzodiazepine, possibly Valium load during seizure treatment. Seen by neuro & psych, thought to have convulsive syncope, Rule out Benzodiazepine withdrawal, & not thought to be suicidal.

2 days after admission, found by Psychiatry consult to be wandering in hallways, with delusion/hallucination of 2 children tormenting him under his bed, with agitation, disorientation. Diagnosed with delirium secondary to Benzodiazepine withdrawal, treated with Ativan 2 mg every 2 hours prn (required–>16mg), & transferred to Medical ICU for observation. Treated with Haldol 5 (mg) that pm after he put his hand through a window. Delirium resolved after 1 day in Medical ICU, with increased Benzodiazepine treatment. Noted by Psychiatry consult 8/25 to be oriented, non suicidal, & without Psychiatric (?abbreviation unclear), & transferred to Eye6 for Psychiatric evaluation and treatment.

As above, patient notes approximately 6 months history of dysphoria anhedonia, increased appetite, decreased self esteem increased guilt, increased hopelessness. Notes some psychomotor slowing, (abbreviation unclear). Denies ever history of increased energy, decreased need for sleep racing thoughts. Denies ever suicidal/homicidal ideation. Denies Auditory/ Visual/Hallucinations, or olfactory hallucinations (?), or automatism (?), incont(?inence), last time. Positive chronic anxiety, related to panic but separate.

Per History of Present Illness. At 17 years old, father gave him Prozac for “depression” (patient describes some Temporary Improvement, but no dysphoria/anhedonia). Patient became very agitated and discontinued immediately.

ALCOHOL AND DRUG HISTORY: Denies Ethanol—-never until 2 weeks
Prior To Admission, then 1/2 bottle gin. Within(?) 2 weeks (secondary
to “panic”)
Never tobacco, Marijuana, Cocaine, Intravenous Drugs

FAMILY PSYCHIATRIC AND ALCOHOL AND DRUG HISTORY: Father positive (for) panic disorder x >20 years, untreated; Father’s sister mentally retarded; mother’s sister “dysthymic.” Family medical: mother positive Graves Disease, cystic breast father kidney stones

Lives with parents, 10 year old sister. Has car, travels about; has job (research assistant at Albert Einstein). Lives in Riverdale.

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(Initial evaluation at Presbyterian Hospital, 8/27/93, after Seth was
transported by ambulance from the Intensive Care Unit of Allen Pavilion)

The Presbyterian Hospital

PSYCHOSOCIAL HISTORY: Nl (normal) L&D (?), nl milestones, Father (is a) psychiatrist, mother homemaker, 21 year old sister, 10 year old sister. EDUCATIONAL HISTORY: Graduate from Lehman College.
2 months ago, works as research assistant at Albert Einstein. Upset over bad rec(ommendation) from Teachers—>mpt accepted to grad(uate program.

ECONOMIC SITUATION (i.e., self supporting, disability, public assistance): supports self

Crohn’s Disease diagnosed at 16 years old, good control – has been
on Asulfadine/Dipentum years ago. Denies bleeding,
sz (seizure), NkDA (?) complains allergy—>berries, dairy
urinary frequency/incontinence
Rule out Benzodiazepine dependence/withdrawal
c) CURRENT MEDICATIONS: Ativan 2 mg p.o. every 4 hours.
(nothing filled in here)

Page 31/37

The Presbyterian Hospital

MENTAL STATUS: Well Developed Well Nourished white male, unshaven, in hospital garb, smiling
APPEARANCE: with good eyecontact, pleasant & cooperative
MOTOR BEHAVIOR: No psychomotor excitation or retardation, calm bearing
MOOD&AFFECT: dysphoric, anxious at times, affect full range with brightening, not labile
Normal tone/rate/prosody goal directed without
Loosening of Association/Flight of Ideas/pressure Negative PI/TI/TB/TW/10R (?)
Remembers delusions of 4 days ago, laughs at that—states that
it was not real. Denies Audio/Visual/olfactory Hallucinations
SUICIDAL: a)IDEATION none, denies ever
b) Potential none apparent

SENSORIUM / ORIENTATION: Alert, Oriented to Columbia University Medical Center, 8/27/93
Registers 3/3, 3/3 after 5 minutes, positive serial seven (subtractions), spells world forward and
reverse, digit span 6forward, 5 reverse, abstract normal to spilt mild, glass houses, positive
INTELLIGENCE: Above average
JUDGMENT/IMPULSE CONTROL: intact to mail letter
ATTITUDE TOWARDS ILLNESS: agrees to admission but may be guarding history

Page 32/37

(nothing filled in on page except signatures, see below)


Page 33/37

8/27/93 R2 (second year resident) note
Called To See Patient during my Psychiatric workup, after final diagnostic assessment (?unclear abbreviation)
Physical Exam (per Dr. Motz). Events of afternoon as follows:
~ 1:00-1:20 Patient seen by Beth, R.N. History taken
~ 1:15-3:15 I sat with patient in his room for initial examination
Patient was Alert & Oriented, pleasant & cooperative,
and without any complaints. Please see Psych workup
~ 3:15 I left patient room with patient. He went to phone to
call his father, and then had vitals taken.
vital signs stable.
~ 3:40 I returned to patient room. I called to him in
the bathroom, and asked for his father’s office
phone #. Patient answered that he did not know
the number. I asked why not, and he stated
that he just did not know it. His voice was calm.

As I was writing my note, it came to my attention that patient had been coded after found in the bathroom unresponsive. I provided relevant information to code team.

My initial diagnostic impression was that this was a 23 year old male with almost daily panic attacks x 2 years, and signs and symptoms (of) depressive diagnosis(?) x 6 months, & chronic Benzodiazepine use x 2 years (until at least 2 weeks Prior To Admission) |who was admitted 6 days ago following a seizure, treated x 6 days for presumed Benzodiazepine withdrawal, and transferred to Psychiatry. Patient denied recent Benzodiazepine or other drug use. Initial plan was to complete medical assessment, continue treatment for Benzodiazepine withdrawal, and begin workup for signs and symptoms (of) panic, & depression, including further history, organic workup.

S. Seidman, PGY2, Psychiatry
Ann Swen(?), M.D.

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8/27/93 MJR Arrest Note
Patient was found by nursing staff unresponsive in bathroom without pulse. Arrest called. Patient was pulseless & apneic when I arrived. CPR being instituted A “quick look” with paddles showed asystole. Central venous access was obtained & patient was given epinephrine/atropine x 1. CPR was continued. Patient was intubated with bilateral breath sounds auscultated. EKG leads applied
(image of flat line EKG is presented)

Rhythm asystole as above & verified in multiple leads. CPR continued. Patient given Narcan & D50(?) 1 amp – IVD. Another epinephrine & atropine given.
(image of flat line EKG is presented)

Rhythm as above – asystole verified in multiple leads.
Epinephrine & atropine given ABC obtained – looked poorly oxygenating. Two amps of NaHCO3 given CPR
continued. rhythm as below
(image of flat line EKG is presented)

Patient still asystole. Given epinephrine & atropine again.
CPR continued. Patient still pulseless & apneic.
(image of flat line EKG is presented)
Rhythm as below. Arrest terminated secondary to cardiovascular
unresponsiveness @ 4:35PM
Mat Mower

Page 35/37

This 23 year old single white male was transferred from Allen Pavilion today with diagnosis of panic disorder and rule out Benzodiazepine withdrawal, was admitted at 1:PM and found unresponsive at 4:20 and pronounced dead at 4:35.

The patient is a recent college graduate living with his parents. He had an approximately 2 year history of panic symptoms and was receiving Xanax up to 4 mg every day from his psychiatrist father Dr. Ralph Speken. The patient also had a 6 month history of some depressive symptoms. Patient’s father had apparently completed a Xanax taper over (?a) 2 week period and the patient then began seeing a Dr. Quen who started elavil. (There are discrepancies between the patient’s history – He denies recent Xanax use, and the Father’s history – He reported (?an) empty Bottle of Xanax), up to 60mg qD.

On 8/21/93 the patient lost consciousness – witnessed by 10 year old sister – and was admitted to Allen Pavilion to rule out Elavil toxicity and rule out seizure. He was evaluated on 8/22 by Neurology and 8/23 by Psychiatry. He was found with Paranoia and visual hallucinations on 8/23 with diagnoses rule out Xanax dependence/withdrawal, rule out post concussive syndrome, Panic Disorder, rule out (?) His workup included negative CT scan of head, negative Lumbar Puncture on 8/23 He was transferred to the ICU for management of probable Xanax withdrawal (the father revealed his suspicion of Xanax use/abuse). He was managed (?with) Ativan 2q 4 IV then 2mg q 4 (hours) PO starting 8/26. On 8/26 patient was felt to be medically stable for transfer to Eye-6 psych unit by ICU Attending/residents and B7 Psychiatry consult. He was transferred by ambulance, arriving 1:00PM. He was seen by (?) (at approximately) 1:00-1:20

Page 36/37

Resident evaluated patient (at approximately) 1:15 – 3:15 (PM), recontacted patient (at approximately) 3:40 (PM). Patient was found unresponsive by RN at 4:10 (PM), code called, patient pronounced dead at 4:35PM.
The resident had completed evaluation (routine procedure consult) and was writing up impression note. Initially diagnostic impression was of rule out Panic Disorder: no Major Depressive Disorder: rule out Benzodiazepine Abuse/withdrawal; no Benzodiazepine withdrawal delirium, resolved; no (?overt delusions). the patient was, on the unit, fully oriented, calm, cooperative, without agitation, without thought disorder, or hallucinations and denied suicidal ideation/homicidal ideation. He was noted to have stable vital signs at approximately 3:15. He was scheduled to be seen by medical consult to complete evaluation. Medical consult was on floor to see patient However patient coded as above

Patient’s father contacted, AOD (?Attending of the Day) and Carol (?name illegible) contacted. Doctors (?name illegible) and Stevenson contacted.
Christopher Johannes(?), M.D.

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8-27-93 Nursing Admission Summary
Transferred in from Allen – 23 year old Psychology student. History of panic attacks, fearful of crowds, able to continue (?with) school for the past 2 years only by taking Xanax 4mg/day – Being treated by own father. Had a “seizure” 2 weeks ago at home. Patches of reddened areas over nose & face from falling on face. Seizure patient attributes from rapid Xanax tapering. Admit to Allen – last week became delusional & out of control, needed restraints. Presently alert/oriented x2. Tearful episodes & depressed Denies suicidal ideation at present.
(illegible name) RN

8/27/93 Attending
Patient arrived via ambulance from Allen Pavilion at 1pm approximately. He was interviewed by nursing until 1:20/pm then by Dr. Seidman, PGY II, until 3:30/pm. At approximately 3:40/pm Dr. Seidman spoke with patient who at that time was in the bathroom with door closed. At approximately 4:10/pm patient was discovered in his bathroom unresponsive Patient was nude, sitting on floor between wall & toilet. (toilet contained stool) cardiac arrest was immediately called, CPR began- Patient intubated. 4:30/pm patient was pronounced dead.
Ann Geller(?), M.D.