CHIEF COMPLAINT: Narcotic withdrawal.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who sounds like she has developed a narcotic addiction. It sounds like it started with management of chronic pain and had gotten out of control. She had gotten to the point where she was using three to four Duragesic patches per day instead of the prescribed one for every two days. This came to light during this current pregnancy. Her physicians were made aware of it, and she has been following with the outpatient treatment program.
Apparently, earlier this evening, she was using her last patch when it caught on her clothing and got pulled off of her. She says when she went to put it back on, the patch had been disrupted. She says she got a rush of euphoria, like she was getting a large dose of the medication and, when she pulled it off a short time later, started to develop narcotic withdrawal symptoms; runny nose, sweats, abdominal cramping. She contacted her doctor who directed her to the emergency room for evaluation.
PAST MEDICAL HISTORY:
1. Fibromyalgia.
2. LEEP procedure.
3. Chronic back pain.
4. Prior kidney stone.
5. Prior cholecystectomy.
6. Alcoholism.
7. Gastric bypass.
CURRENT MEDICATIONS:
1. Duragesic.
2. Effexor.
3. Vitamins.
4. Procardia.
ALLERGIES: No known allergies.
SOCIAL HISTORY: Nonsmoker, nondrinker. She is 27 weeks pregnant, G2 P0, one prior miscarriage.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: All systems are reviewed and negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 134/88, temperature 98.4, pulse 112, respirations 21, 98% on room air.
GENERAL: The patient is a (XX)-year-old who is awake, alert, shaky, and anxious, in no obvious distress.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, reactive to light. Extraocular muscles are intact. No nasal discharge. No facial trauma. Intraoral exam shows moist mucous membranes with no tonsillar enlargement or exudate. Tympanic membranes are normal. The canals are clear.
NECK: Supple with no cervical lymphadenopathy. No meningismus. No goiter.
CARDIOVASCULAR: Regular rate, without murmur, rub or gallop.
PULMONARY: Equal breath sounds bilaterally with no wheezing, rales or rhonchi. There is no chest wall tenderness or instability.
ABDOMEN: No external sign of injury. Bowel sounds are present. Abdomen is soft, nontender. No rebound, no guarding, no rigidity. There are no palpable masses. There is no flank pain on exam. She does have a gravid uterus palpable in the lower abdomen.
EXTREMITIES: Strong peripheral pulses. There is no clubbing, no cyanosis and no edema.
SKIN: No rash.
EMERGENCY DEPARTMENT COURSE: While here in the emergency room, we did pull a report and, in looking at this, it becomes very obvious that the patient was abusing her Duragesic patches, looking back over the past several months. It looks like in October, instead of going through 15 Duragesic patches which should have been a month’s supply, she went through what looks like 70 of those 75 mcg Duragesic patches.
At this point, the patient is showing some withdrawal symptoms. We are not completely clear that with her just having this patch come off earlier today that she really should be experiencing significant withdrawal symptoms. However, she does seem to have been honest with us, and we are going to try to give her the benefit of the doubt. With that being the case, she received IM morphine and Phenergan here in the emergency room and had a Duragesic patch placed.
We spoke with Dr. John Doe regarding this management and, because the patient had had some cramping earlier, we are going to send her up to labor and delivery so they can do a period of fetal monitoring prior to discharging her home.
FINAL DIAGNOSIS: Narcotic withdrawal.
PLAN:
1. The patient is to follow up with her OB/GYN.
2. Follow up with her pain specialist.
DISPOSITION: The patient is going to be sent to labor and delivery for monitoring.
