history of present illness: this is a 23-year-old white male with a history of polysubstance abuse, who presented to in the early morning of after being found unresponsive on the floor in his home, reportedly after emergency medical service was notified, and the patient was found in similar condition by emergency medical service and he was intubated in the field. the patient presented to where he was found to be hemodynamically stable and with a patent airway. due to concern over his overdose, the patient was transferred to the before being transferred over, the patient did get one dose of activated charcoal, which he kept down. after the medical flight, the patient presented to the emergency room where he became very agitated and self-extubated. in addition, two doses of activated charcoal were attempted to be administered, both of which did not stay down in the stomach. due to concern for airway protection, the patient was reintubated and placed on a mexazolam drip as well as vecuronium. the patient was subsequently admitted to the medical intensive care unit. of note, before transfer to , laboratories were drawn at which included a urine toxicology screen which was positive for amphetamines, benzodiazepines, and cocaine. past medical history: the patient has been hospitalized twice for substance overdoses; the first of which the patient reports was related to recreational overdose, the second of which may have been related to a suicide attempt. allergies: no known drug allergies. medications on admission: the patient denies being on any. family history: family history was not obtained. social history: the patient drinks about one pint of vodka per day. in addition, he has used gamma hydroxybutyrate and ephedrine; although, he denies use of benzodiazepines or cocaine. physical examination on presentation: physical examination on admission to revealed temperature of 98.8, blood pressure of 160/100, heart rate of 100. his respiratory rate revealed the patient was on the ventilator on synchronized intermittent mandatory ventilation and pressure support with an fio2 of 100%, respiratory rate set at 12, tidal volume of 700; on this, the patient had a spontaneous respiratory rate as high as 10 and had achieved an oxygen saturation of 100%. on initial presentation, the patient was intubated and sedated. his pupils were 3 mm and reactive bilaterally. he had no scalp or other head lesions. he did have moist mucous membranes, and his tympanic membranes were intact bilaterally. his oropharynx revealed dried blood in the right nares where an nasogastric tube had been placed. his neck was supple without lymphadenopathy. his chest revealed clear breath sounds bilaterally (per the emergency department note). heart examination revealed first heart sound and second heart sound with tachycardic rate, and a regular rhythm. abdominal examination was soft, nontender, and nondistended, with positive bowel sounds. his extremities revealed there was no clubbing, cyanosis or edema. no evidence of other trauma. neurologic examination on initial presentation revealed the patient was sedated. subsequently on admission to the medical intensive care unit, the patient did appear to have fasciculations in the legs bilaterally as well as in the neck muscles. pertinent laboratory data on presentation: laboratories from an outside hospital revealed a white blood cell count of 9.7, hemoglobin of 18, hematocrit of 53.4, with a mean cell volume of 91, platelets of 217. he had a differential of 79.5% polys, and 13% lymphocytes, 5.7% monocytes, 1.5% eosinophils, and 0.3% basophils. his chem-7 at revealed a sodium of 143, potassium of 4.3, chloride of 107, bicarbonate of 25, blood urea nitrogen of 11, creatinine of 1, glucose of 120. a serum toxicology screen here was negative. urine toxicology screen, per an outside hospital, as mentioned with positive benzodiazepines, positive cocaine, and positive amphetamines. an arterial blood gas taken post intubation here revealed a ph of 7.32, pco2 of 47, and a po2 of 400. radiology/imaging: a chest x-ray post second intubation revealed an elevated right hemidiaphragm with normal cardiac silhouette and contours. electrocardiogram from the outside hospital was remarkable for a normal sinus rhythm at 78, with normal intervals. no st segment changes or t wave changes. hospital course: the patient was admitted to the medical intensive care unit, where on initial presentation there was concern for the fasciculations. there was a thought process that this may represent gamma hydroxybutyrate withdrawal; a rare, but no unheard of effect of gamma hydroxybutyrate. there was also concern that this may represent reaction to the vecuronium. vecuronium was d/c'd, he was reversed with glycopyrrolate and neostigmine, and the patient was weaned from the ventilator and extubated. post extubation the patient's agitation and fasciculations went away. the patient did remain groggy throughout the first day of his admission until the evening. before coming out of mental cloudiness, the psychiatry team did come to evaluate him, as there was concern on the part of his family (specifically, his sister) that this may have represented a suicide attempt; although, the patient denied this. psychiatry determined on the first date of admission that it was unclear given his mental state what was going on and wanted him to remain in the hospital with a one-to-one sitter and for them to evaluation him the next day to make a decision on potential for inpatient hospitalization. the patient did remain overnight without event, and on the morning of the second day of admission, psychiatry came to evaluate him and felt that his overdose was not consistent with a suicide attempt and felt that he was safe to be discharged home. from a medical perspective, the patient remained hemodynamically stable and was afebrile throughout his course. he did have an elevated creatine phosphokinase on admission (in the 1300-range) with a mb of 2. the creatine phosphokinase did trend down to the 600s on the second day of admission, and his creatinine remained stable at 1.1; thusly ruling rhabdomyolysis. discharge status: the patient was to be discharged home. discharge followup: he was discharged, to follow up at his local mental health center. he was offered voluntary psychiatric admission for his substance abuse, but he declined this at that time. in addition, the patient asked for human immunodeficiency virus test before his discharge. this was performed, and the results will be followed up upon. the patient will follow up from a medical perspective with his primary care physician, . , in . medications on discharge: none. dr., 12-664 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Other, mixed, or unspecified drug abuse, unspecified Poisoning by benzodiazepine-based tranquilizers Acute respiratory failure Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted Poisoning by tranquilizers and other psychotropic agents, undetermined whether accidentally or purposely inflicted Poisoning by other and unspecified general anesthetics Surface (topical) and infiltration anesthetics