4/18/2023 0 Comments Tremulous tongue![]() ![]() Empiric antibiotics were administered for spontaneous bacterial peritonitis (SBP) prophylaxis, but there is no documentation to support infection. The patient was admitted with plan for intravenous fluids (IVF) and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. She developed tremors while in the emergency department (ED), but did not have vomiting, delirium, or seizures. She did not have tachycardia or arrhythmia. The patient was hemodynamically stable and afebrile. This patient was admitted after presenting with alcohol intoxication. No, the proposed inpatient admission was not medically necessary. Admission day 7, vital signs were stable (VSS). The plan was for the last dose of intravenous (IV) antibiotics. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 3. ![]() Admission day 6, vital signs were stable (VSS). Admission day 5, vital signs were stable (VSS). Ativan was increased to two milligrams very six hours (q6h) by mouth (po) and intravenous (IV) three times a day (TID) as needed (PRN). Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 13. Admission day 4, vital signs were stable (VSS). Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 12. Admission day 3, vital signs were stable (VSS). Platelets were 26 as a result of alcohol-induced thrombocytopenia. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 4. Admission day 2, vital signs were stable (VSS). The plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol and intravenous (IV) antibiotics for spontaneous bacterial peritonitis (SBP) prophylaxis. The patient was admitted with alcohol withdrawal syndrome. Repeat exam remarkable for abdominal distention, nontender. The patient became tremulous and had tongue fasciculation. She was given a total of 75 milligrams (mg) of Librium in the emergency department (ED). The patient refused detox in the emergency department (ED). Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 7. Labs were remarkable for alcohol (EtOH) 363. Vital signs (VS) revealed temperature 98.6, heart rate 80, respiratory rate 20, blood pressure 112/78, and oxygen saturation 97%. This female with a history of alcohol abuse presented to the emergency department (ED) with alcohol intoxication. The insurer denied the inpatient admission. ![]()
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |