Poisoning by heroin Opioid abuse unspecified Other mixed or unspecified drug abuse unspecified Cocaine abuse unspecified Tobacco use disorder Poisoning by analgesics antipyretics and antirheumatics undetermined whether accidentally or purposely inflicted Personal history of other infectious and parasitic diseases Accidents occurring in unspecified place
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
No Drug Allergy Information on File
 
Attending: ___
 
Chief Complaint:
Heroin Overdose
 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
The pt is a ___ y/o F admitted after heroin overdose. The pt 
reports a past history of heroin abuse with recent relaps six 
months ago. Pt went to rehab at ___ in ___ approx 1 week ago 
for 7 day stay but felt her rehab stay didn't address her 
addiction issues. She reports being treated with librium and 
clonidine. She completed her rehab stay two days ago. She says 
that due to ongoing stress within her marriage she again used 
heroin earlier today. She reports that after feeling her inital 
rush after her injection she began reacting poorly and feeling 
like she was going to pass out. The people around her called 
EMS. Upon EMS arrival she became concerned about possessing 
additional heroin and she swallowed her other bag in her 
possession, states less than 1gm of heroin. The patient denies 
any attempt to harm herself. Denies fear of domestic violence. 
She was found unresponsive on a basketball court by EMS. On 
arrival to ED vitals T 97.8, HR 80, RR 12 BP 120/61, SaO2 %NRB. 
She was responsive to verbal stimuli. She received naloxone X 4 
in the ED. She was admitted to the ICU as she was having 
continued episodes of somnolence. 
.
On arrival to the FICU the patient was awake and alert. She was 
able to ambulate from the transport gurney to the bedside 
without difficulty. Vitals stable. Pt was cooperative with 
questioning and expressed an interest in obtaining outpatient 
therapy. Denies use of other illicit drugs. 

 
Past Medical History:
Hepatitis C - reports due to tatoo, no prior treatment
Heroin abuse - states her addiction began after she was given 
percocet and oxycodone for back pain s/p MVC many years ago. Had 
previously been clean for ___ years prior to relapsing 6 months 
ago

 
Social History:
___
Family History:
unknown patient is adopted
 
Physical Exam:
Gen: alert, oriented X3, NAD
CV: RRR, no MRG
Resp: CTAB, no WRR
Abd: soft, NT/ND NABS
Ext: no edema
Skin: tatoo left shoulder, no needle tracks

 
Pertinent Results:
___ 02:21PM   WBC-12.0* RBC-4.71 HGB-14.3 HCT-41.4 MCV-88 
MCH-30.3 MCHC-34.4 RDW-14.1
___ 02:21PM   NEUTS-53.1 ___ MONOS-4.4 EOS-1.0 
BASOS-0.7
___ 02:21PM   PLT COUNT-362
___ 02:21PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG 
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 02:21PM   GLUCOSE-147* UREA N-22* CREAT-1.0 SODIUM-146* 
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-26 ANION GAP-19
___ 02:21PM   CALCIUM-10.0 PHOSPHATE-7.3* MAGNESIUM-2.3
___ 08:35PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 
LEUK-NEG
___ 08:35PM URINE  COLOR-Yellow APPEAR-Clear SP ___
___ 10:00PM URINE  bnzodzpn-POS barbitrt-NEG opiates-POS 
cocaine-POS amphetmn-NEG mthdone-NEG
___ 10:00PM URINE  HOURS-RANDOM
___ 03:48AM BLOOD ALT-59* AST-43* AlkPhos-56 TotBili-0.5

___ CXR FINDINGS: There is relative ___ of the 
lungs with no consolidation 
or edema evident. The mediastinum is unremarkable. The cardiac 
silhouette is 
top normal for size. Minimal left basilar atelectasis is evident 
with a 
slightly elevated left hemidiaphragm. There is no pleural 
effusion or 
pneumothorax. The visualized osseous structures are 
unremarkable. 
  
IMPRESSION: No acute pulmonary process. 

 
Brief Hospital Course:
The pt is a ___ F admitted with heroin overdose. 

Heroin Overdose - pt w/ respiratory depression in ED requiring 
narcan. On arrival to ICU this has resolved.  Need for recurrent 
narcan may be related GI absorption of swallowed heroin. It was 
unclear whether the bag of heroin ingested had ruptured and she 
had absorbed the drug.  Toxicology was contacted and they stated 
safest would be to start the patient on golytely until the 
heroin bag passes or her stool output is clear and to monitor 
her in a medical setting until this is complete.  She signed out 
against medical advice, understanding the risks of this 
including GI obstruction, heroin overdose or death.  Discharged 
with recommendations to follow up with her PCP for help with a 
drug rehab program.  upon discharge no signs of heroin 
intoxication or withdrawal, the patient has capacity to make 
this decision.  She denies any thoughts of suicide.  

Polysubstance abuse - pt with recent relapse despite rehab stay. 
Urine tox positive for cocaine, benzos and opiates. Pt reports 
benzo screen positive due to librium use at rehab. 

Hep C - pt reports stable LFTS followed as outpatient. Recommend 
continued outpatient management. 
 
Medications on Admission:
Medications: none
 
Discharge Medications:
none
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis: 
Heroin Overdose

 
Discharge Condition:
Against Medical Advice.  Vitals stable.  Normal Mental Status.  
No signs of heroin withdrawal or intoxication.

 
Discharge Instructions:
You were admitted for a drug overdose.  You stated that you 
ingested a bag of heroin, it is important that you be monitored 
in a medical setting in case the bag ruptures and you absorb 
this heroin.  

You stated that you understand the risks of leaving including 
heroin overdose, intestinal obstruction, or even death and that 
you are willing to take the risks and leave Against Medical 
Advice ("AMA").

Please call your doctor or return to the emergency room 
immediately if you have abdominal pain, difficulty breathing, 
constipation, nausea, lethargy or if you begin to feel the 
effects of the heroin you have ingested.
 
Followup Instructions:
___

{'Heroin Overdose': ['Poisoning by heroin'], 'Opioid abuse': ['Opioid abuse'], 'Cocaine abuse': ['Cocaine abuse']}