Resident Physician: Kenneth Acha, MD, UCR FM PGY2
Attending Physician:
Consulting Physician:
Reason for Consult: Substance abuse / Anxiety / Depression
HISTORY OF PRESENT ILLNESS:
PAST PSYCHIATRIC HISTORY.
Patient denies psychiatric problems in the past.
SUBSTANCE ABUSE HISTORY.
Patient has been abusing alcohol now for some time.
PAST FAMILY/SOCIAL HISTORY.
Patient denies tobacco abuse. He denies any drug abuse. He admits to occasional alcohol use. He states that he drank 2 shots of liquor
in the morning today due to lower extremity leg pain.
PAST MEDICAL & SURGICAL HISTORY:
CURRENT MEDICATIONS:
(Ipatient_Meds)
ALLERGIES:
REVIEW OF SYSTEMS: All 10 systems reviewed are negative except as stated in HPI
PHYSICAL EXAMINATION:
VITAL SIGNS:
MENTAL STATUS EXAM
GENERAL APPEARANCE: Appropriate, stated age.
BEHAVIOR: cooperative, agitated.
SPEECH: Normal
MOOD/AFFECT: Anxious, depressed, worried.
THOUGH PROCESS: Normal, logical
HALLUCINATIONS: No Auditory or visual hallucinations.
DELUSIONS: None
SUICIDAL: No
HOMICIDAL: No
ORIENTATION: X3
ATTENTION: Alert
CONCENTRATION: Intact
FUND OF KNOWLEDGE: average
MEMORY: Intact
ABSTRACT REASONING: Intact
JUDGMENT: Fair
INSIGHT: Fair
INTELLIGENCE: Average
GAIT: Stable.
CURRENT CONDITION: Improving
LABS:
IMAGING:
SIDE EFFECTS: None. No EPS, Sedation, Constipation.
TARDIVE DYSKINESIA: No
DIAGNOSTIC IMPRESSION
PROGNOSIS: Fair
ASSESSMENT & PLAN:
Depression and anxiety, multifactorial (Clinical MDD vs. alcohol induced, vs grief)
Altered mental status 2/2 to alcohol intoxication on admission
Substance used dependence
Transaminitis
Elevated lipase
PLAN
Social services consult to corroborate his story. Also, assess the patient for disposition either to Michigan or to an alcohol rehab center.
Continue Ativan for a total of five days since admission and then taper off.
No Librium secondary to liver problems.
Start Celexa 10mg
Increase dose of Trazodone to 50mg
Treatment modalities risks and benefits discussed. Patient understands and consents to treatment.