Case 2_Ennis 2024

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School

Bristol Community College *

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Course

121

Subject

Chemistry

Date

Feb 20, 2024

Type

docx

Pages

2

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Report
Patient Presentation Name: Raymond Ennis Height: 178 cm Age: 35 Weight: 80 kg Sex: Male Allergies: NKDA Medications: risperidone 4mg/twice per/day; gabapentin 400mg/three times per/day; alprazolam 2mg PRN Last Oral Intake: Patient has refused food and drink since admission. HR: 137 BP: 152/98 RR: 28 SpO 2 : 94% Pupils: Equally dilated, NR Skin: Warm, slightly flushed, diaphoretic Glucose: 90 mg/dL Temp: 40.1C Case Description: Mr. Ennis is a 35-year old male who was transported to the ED by EMS after neighbors reported hearing screaming and banging inside his apartment. Upon arrival, police and EMS found Mr. Ennis in a presumed psychotic episode with several cuts and bruises. The presumed diagnosis was supported by one of the paramedics who had previously cared for Mr. Ennis and was aware of his diagnosis, paranoid schizophrenia with aggressive features. His schizophrenia is managed with risperidone and gabapentin however Mr. Ennis freely states that he often discontinues his medication. Upon admission to the ED Mr. Ennis remained combative and was administered 5mg haloperidol IM and was placed in loose restraints. Twelve hours have now passed since Mr. Ennis was admitted to the ED. Over this time period, he required 2 additional doses of haloperidol (5mg IM x2) to control combative behavior and positive delusions. At the time of this review, Mr. Ennis has had 3 doses (5mg each) of haloperidol. At this time, Mr. Ennis has acutely developed an inability to form coherent sentences along with pronounced muscle stiffness and bradykinesia. A Chem7, CBC with differential, CK level and toxicology screen were ordered. You Task: Assess the patient’s present condition; determine the proximate cause of his rapid instability, communicate your recommendations to the senior medical staff using SBAR technique. Chem7 CBC Na (135-145): 139 mEq/L WBC (3.5-11): 17.2 K/uL K (3.6-5.1): 3.7 mEq/L HGB (11.0-15.0): 12.0 g/dL Cl (98-110): 99 mEq/L HCT (32-45): 36% CO 2 (20-30): 29 mEq/L PLT (140-400): 362 BUN (6-24): 26 mEq/L Creat (0.4-1.3): 2.3 mEq/L WBC Differential Neutrophil (50-65): 60% CK (60-400 U/L) : 3,400 U/L Band Neutrophil (0-5): 6% Monocyte (2-8): 4% Lymphocyte (20-40): 25% Basophil (0.5-1): 1% Eosinophil (1-4): 4%
Toxicology Screen: NEG
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