history of present illness: this is a 30-year-old female with a history of suicidal ideation and attempts, schizoaffective disorder, type 2 diabetes, and a history of an eating disorder (refusing to eat and drink for days at a time) who was an inpatient at hospital for two weeks for purging behavior and was found to have blood sugar of 40 on the morning of presentation. the patient was given glucophage and sent to the emergency department for further workup. per further history, the patient had continued to refuse her glyburide while she had purging behavior and also reported she had not been taking her other medications. in the emergency department, her blood sugar was 90. the patient became extremely agitated and received ativan and haldol while in the emergency department. past medical history: (past medical history is significant for) 1. type 2 diabetes. 2. schizoaffective disorder. 3. hypertension. 4. asthma. 5. bulimia. 6. history of previous suicide attempts. 7. history of a seizure disorder. allergies: the patient is allergic to penicillin, motrin, and tylenol (reactions are unknown). medications on admission: (medications included) 1. flovent. 2. glyburide 5 mg p.o. once per day. 3. enalapril 5 mg p.o. once per day. 4. serevent. 5. neurontin 600 mg p.o. twice per day. 6. trileptal 600 mg p.o. twice per day. 7. topamax 200 mg p.o. once per day. 8. paxil 20 mg p.o. once per day. 9. cogentin 1 mg p.o. once per day. 10. buspar 15 mg p.o. twice per day. 11. seroquel 25 mg p.o. three times per day. 12. albuterol as needed. 13. benadryl as needed. 14. mylanta as needed. 15. milk of magnesia as needed. social history: the patient comes from a group home. family history: family history was noncontributory. physical examination on presentation: physical examination revealed vital signs in the emergency department with a temperature of 99.5, blood pressure was 150/53, heart rate was 59, respiratory rate was 16, and oxygen saturation was 99% on room air. fasting fingerstick blood sugar was 90 at this time. in general, she was sleeping comfortably, obese. pupils were equal, round, and reactive to light. the mucous membranes were moist. the neck was supple. heart was regular in rate and rhythm. no murmurs, rubs, or gallops. the chest was clear to auscultation bilaterally. the abdomen was obese, soft, nontender, and nondistended. bowel sounds were present. extremity examination revealed there was no clubbing, cyanosis, or edema. pertinent laboratory values on presentation: laboratories on admission revealed sodium was 141, potassium was 3.5, chloride was 112, bicarbonate was 19, blood urea nitrogen was 11, creatinine was 0.6, and blood glucose was 91. white blood cell count was 9.8 (with a normal differential), hematocrit was 37.7, and platelets were 329. urinalysis was negative. urine human chorionic gonadotropin was negative. urine and serum toxicology screens were negative. hospital course by issue/system: the patient was admitted to the medicine service for her agitation, noncompliance with medications, and a history of hypoglycemia. 1. psychiatry/neurology issues: psychiatry was consulted, and the patient remained on a one-to-one sitter. while on the medical floor, the patient made numerous attempts to flee the unit; requiring both mechanical and chemical restraints. on the morning after admission, the patient was noted to have an episode of total body shaking and urinary incontinence which resolved with ativan. a computed tomography of her head was performed at this time which was negative. neurology was consulted and felt that while the patient had received haldol for sedation, which does lower the seizure threshold, that the patient also had a history of not taking her anti-seizure medications for several weeks. the decision was made to minimize haldol use and load the patient up on intravenous dilantin while continuing her oral medications. again, while on the floor, the patient made numerous attempts to flee the floor, and the decision was made to transfer the patient to the medical intensive care unit, continue the patient on her dilantin load, and monitor for seizure activity while administering haldol around the clock and ativan around the clock, in addition to as needed. the patient was transferred to the medical intensive care unit on . her medical intensive care unit course was unremarkable. no seizure activity was noted. the one-to-one sitter was continued. psychiatry continued to follow. changes in her medications were made including an increase in her seroquel. the patient did receive haldol 5 mg three times per day and ativan 1 mg p.o. four times per day around the clock. the patient also remained in mechanical restraints. again, after two days in the medical intensive care unit, no seizure activity was noted. the patient became increasingly compliant with taking her oral medications and tolerating oral intake. all medications were changed over to oral. the patient was seen by neurology who recommended to continue the dilantin for one week at 500 mg total once per day to divide into three times per day dosing for one week and then to decrease by 150 mg p.o. once per day for three days while she continued to get her oral medications. 2. type 2 diabetes issues: for diabetes, the patient was maintained on a regular insulin sliding-scale with fasting blood sugars four times per day. 3. asthma issues: for asthma, the patient was continued on her albuterol. 4. hypertension issues: for her hypertension, the patient was continued on enalapril. 5. prophylaxis issues: for prophylaxis, the patient received an h2 blocker. condition at discharge: condition on discharge was stable. discharge status: discharge status was per psychiatry. discharge diagnoses: 1. seizure disorder. 2. hypoglycemia. 3. noncompliance with medications. medications on discharge: 1. enalapril 5 mg p.o. once per day. 2. albuterol 1 to 2 puffs inhaled q.4-6h. as needed. 3. fluconazole 2 puffs inhaled twice per day. 4. gabapentin 300 mg p.o. twice per day. 5. oxcarbazepine 300 mg p.o. twice per day. 6. topamax 200 mg p.o. twice per day. 7. paroxetine 20 mg p.o. once per day. 8. buspirone 15 mg p.o. three times per day. 9. seroquel 25 mg p.o. three times per day as well as 20 mg p.o. q.h.s. 10. dilantin 200 mg p.o. q.a.m. and q.h.s. in addition to 100 mg p.o. q.p.m. times one week; this was then to be decreased by 150 mg for each of the following three days until the patient is weaned off. 11. a regular insulin sliding-scale. 12. haldol as needed. 13. ativan as needed. discharge instructions/followup: 1. the patient was to follow up with her primary care provider . (telephone number ). 2. the patient was to follow up with her neurologist dr. (telephone number ). 3. in addition, the patient also has a port-a-cath; for which basic maintenance requires access every month using flush with 10 cc of normal saline and flush with 5 cc of 100 units of heparin. 4. please look for any discharge summary addendums which may be necessary. 5. in addition, the patient had her thyroid-stimulating hormone and t4 levels drawn, and the results were still pending at the time of discharge. , m.d.12.aew dictated by: medquist36 Procedure: Other psychiatric drug therapy Diagnoses: Unspecified essential hypertension Asthma, unspecified type, unspecified Other convulsions Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Personal history of noncompliance with medical treatment, presenting hazards to health Schizoaffective disorder, unspecified Bulimia nervosa