Patient was a 82 year old while female who was brought by EMS to the PHD emergency department after being found unresponsive in her room at a rehabilitation hospital.  She had been admitted to the rehab hospital one week prior to presentation to ED for difficulty walking and severe low back pain that was interfering with her activities of daily living.  Apparently, she was found in her hospital room unresponsive.  The nursing staff initiated CPR, called “911”, and the paramedics arrived shortly thereafter and briskly transferred her our ED.

1. Hypertension
2. Chronic low back pain with low back surgery for spinal stenosis in October 2000
3. Osteoporosis
4. Hypokalemia – no specifics known
5. Anemia – no specifics known
6. Urinary incontinence
7. Questionable history of osteomyelitis

1. Enalapril 5 mg PO BID
2. Hydrochlorthiazide 25 mg PO qD
3. Eprosartan 600 mg PO qD
4. Clonidine 0.1 mg PO BID PRN
5. Raloxifene 60 mg PO q Week
6. Alendronate 70 mg PO q Week
7. Rofecoxib 25 mg PO qD
8. Propoxyphene/APAP 100 mg PO q4 hours PRN
9. Ranitidine 150 mg PO BID
10. Cosopt ophthalmic drops 1 drop BID
11. Senna/Docusate 1 PO PRN
12. Zolpidem 5 mg PO qhs PRN

unobtainable

(limited):

Vital signs: No pulse, BP, or respirations detected
Skin: pallor with cyanosis
HEENT: vomitus around mouth, ET tube in place, pupils fixed and dilated
Chest: no spontaneous respirations
CV: no cardiac sounds detected
Abd: soft, nondistended, no masses palpable, no bowel sounds
Neuro: Deeply comaose with no spontaneous movements
Ext: no edema, no pulses