CHIEF COMPLAINT: This is an initial medical assessment on [text name="person1" default=""] who is being admitted for medically managed detox and subsequent residential services for:[checkbox name="sud" value="alcohol use disorder|amphetamine use disorder|cannabis use disorder|sedative,hypnotic,anxiolytic use disorder| opioid use disorder| cocaine use disorder| other stimulant use disorder| hallucinogens use disorder| substance use of inhalants| substance use of other psychoactive substances and multiple drug use"] as evidence by patient's precipitating event, "[text name="variable_precep" default="precipitating event"]" _______________________________________________ HISTORY OF PRESENT ILLNESS: [text name="person1" default=""] is a [text default="" size=2]-year-old [select RACE="variable_2020" value="Caucasian|African American|Asian|Hispanic|Multi-Racial|Native Hawaiian| Other not Listed"], [select name="GENDER" value="male|female|transgender male|transgender female|intersex| non-binary"], admitted to NPNE on [date name="variable_datead" default=" "] with a past medical history of [text default="" size=100]. [textarea name="pmhsuds" default="This patient has been engaging in regular use of ---substance-- since the age of --. This patient currently consumes --- daily. Their last use was: --. This patient recalls no history of sobriety/ This patient recalls their history of sobriety occurring --. They have| have not been in other treatment facilities... This patient notes their pattern of substance use has affected relationships, ADLs, and finances. This patient's motivation for treatment includes--. This patient endorses/denies nicotine use. BAC on admission 0.--. CIWA on admission --"] [checkbox memo="include cravings rating" name="include_cravings" value=""][conditional field="include_cravings" condition="(include_cravings).is('')"]This patient reports their cravings are a [select name="cravings" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10|high|variable|low|consistent|managable"][/conditional] [checkbox memo="include detox info" name="include_detox" value=""][conditional field="include_detox" condition="(include_detox).is('')"] Patient reports withdrawal symptoms as [checkbox name="withsx" value="anxiety|fatigue|shivering|seizures|hallucinations|confusion|chills|malaise|nausea|vomitting|paliptations|chest pain|shortnes of breath|sweating|headaches|irritability|agitation|memory loss|hallucinations|hypertension|muscle aches| tactile disturbances|paranoia|depression| sweats|tremors|diarrhea|constipation|abdominal cramping|fuzzy thinking|denies withdrawal symptoms"][/conditional] [select value="Patient does not have a history of seizure or DTs| Patient has a history of seizure or DTs |"][textarea name="variable_seizureconcerns" default=""] _______________________________________________________________________________ PAST MEDICAL HISTORY: [checkbox name="negpmh" value="Patient denies any significant past medical history or current concerns"] [textarea name="pmhmed" default=" "] Patient denies a history of stroke, seizures, MI, dysrhythmias, heart disease, DVT/PE, kidney disease, pancreatitis, liver disease, COPD, cancer, DM, or thyroid disease. VSS and patient is not in acute distress. [checkbox memo="female only" name="If_female" value=""][conditional field="If_female" condition="(If_female).is('')"] LMP: [date name="3" default=""] [select name="preg" value="Patient is not seeking to get pregnant in the next year| Patient is seeking to get pregnant within the next year"] Birth control methods:[text name="bc" default="none"][/conditional] _______________________________________________________________________________ PAST SURGICAL HISTORY: [checkbox name="negsurg" value="Patient denies any significant surgical history "] [textarea name="pastsurg" default=" "] _______________________________________________________________________________ PSYCHIATRIC HISTORY: [comment memo="symptoms,previous psych hospitalizations, previous psych meds trialed, previous counseling services, current mood"] DIAGNOSES: • This patient [select name="psychdxdx" value="endorses psychiatric diagnoses of:|denies any psychiatric diagnoses"][text name="psychdxex" default=""] SYMPTOMOLOGY: • [textarea name="variable_1psychsx" default="Today, patient admits to multiple depressive symptoms: insomnia, anhedonia, feelings or guilt, depressed mood, poor energy, poor concentration, fluctuating appetite, impulsivity"] • [textarea name="variable_1psychsx2psychsx" default="Today, patient admits to multiple anxiety symptoms: insomnia, poor concentration, sense of impending danger, restlessness, increased breathing and/or heart rate, avoiding triggers, fluctuating appetite"] • [textarea name="variable_1psychsx3" default="Today, patient admits to multiple PTSD symptoms: agitation, irritability, hostility, hypervigilance, self-destructive behavior, anhedonia, nightmares, insomnia, flashbacks, mistrust, panic"] CURRENT PSYCHIATRIC STATUS: • [comment memo="DEPRESSION:"]Patient reports their depression is a [select name="depression" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10|high|variable|low|consistent|managable"]; reports their anxiety is a [select name="anxiety" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10|high|variable|low|consistent|managable"]; reports [select name="diet" value="good|fair|poor|nutrient deficient"] diet. This patient reports they are sleeping on average [select name="sleep" value="0|1|2|3|4|5|6|7|8|9|10"] hours per night with [select name="sleepprob" value="no difficulties|difficulties falling asleep| difficulties with frequent awakenings|difficulties staying asleep| difficulties with nightmares"] • [comment memo="Psychotic Symptoms: (Hallucinations (visual/auditory), Delusions, Paranoia)"][select value="|Patient denies and does not demonstrate current symptoms of hallucinations (visual/auditory), delusions, or paranoia|Patient denies, but demonstrates current symptoms of hallucinations (visual/auditory), delusions, or paranoia| Patient does not endorse current hallucinations (visual/auditory), delusions, paranoia, but reflects a history of symptoms| Patient has current hallucinations (visual/auditory), delusions, paranoia |"]. [select name="variable_manic" value="Patient denies and does not demonstrate symptoms of mania: distractibility, irritability, grandiosity, flight of ideas, increased goal-directed activities, rapid or increased speech, thoughtlessness|Patient denies but demonstrates symptoms of mania: distractability, irritability, grandiosity, flight of ideas, increased goal-directed activities, rapid or increased speech, thoughtlessness|Patient confirms and demonstrates symptoms of mania: distractability, irritability, grandiosity, flight of ideas, increased goal-directed activities, rapid or increased speech, thoughtlessness| Patient confirms without demonstration of symptoms of mania: distractability, irritability, grandiosity, flight of ideas, increased goal-directed activities, rapid or increased speech, thoughtlessness"] MEDICATIONS: • [select name="psychmeds" value="|Current medications include:|Trialed medications include:|There are no current or trialed medications"][text name="psychmedsex" default=""] PREVIOUS PSYCHIATRIC EVENTS: • [select name="variable_1psychhospital" value="|This patient denies a history of psychiatric hospitilization|This patient endorses a history of psychiatric hospitalization| This patient does not recall psychiatric hospitilization"][text name="variable_psychhos" default=""] • [comment memo="Suicidal intent/plan:"] [select value="|Patient denies current suicidal ideation| Patient endorses suicidal ideation with plan and intent| Patient endorses a history of suicidal ideation, but no current thoughts| Patient endorses suicidal ideation, but is without intent and/or plan|Patient has a history of suicidal ideation and attempt, but is without current ideation|Patient refuses to answer question|"]. • [comment memo="Self-injurious:"] [select value="|Patient denies current para-suicidal behavior or ideation|Patient endorses self-harming behaviors| Patient endorses self-harming behaviors when intoxicated| Patient refuses to answer questions regarding this|"] _______________________________________________________________________________ PSYCHOSOCIAL HISTORY: • LEGAL HISTORY: [textarea name="legal" default="Denies any current or past history of jail/prison, probation/parole, charges or pending charges."] • TRAUMA HISTORY: [select value="No history of head injuries or traumatic brain injuries|Past history of traumatic brain injuries resulting from |Patient has an underlying cognitive impairment from |"] [textarea rows="2"]. [select value="Denies history of trauma (sexual, emotional or physical)|Reported having a history of trauma (sexual, emotional or physical) but did not want to elaborate|Reported past traumatic experiences to include |"][textarea rows="2"]. • FAMILY CONSTELLATION/SUPPORT: Patient has [select value="no|1|2|3|4|5|6|7|"] [select name="householdppl" value="children|pets|"]. Patient is [select name="variable_status" value="single|married|partnered|divorced|separated|widowed"] • RESIDENCE: [select name="res2" value="independently|with family|with children| with partner| with roommates| homeless| transient| shelter-based| residing with friends or family as short term guest| residential facility| nursing home| refugee| correctional facility| mobile home"] • SOCIAL SUPPORT: Patient identifies [checkbox value="having no one|significant other|family|neighbors|extended family|children|friends|church members"][textarea rows="1"] as social-support network. • COMMUNITY SUPPORT:[text name="communitysup" default=""] • EDUCATION: Highest level of education is [select value="high school|an undergraduate degree |a graduate degree in |some high school|some college|currently in grade school|currently in grad school"]. • FINANCIAL SUPPORT: Patient is [select value="unemployed|currently on disability due to mental health condition|currently on disability due to medical condition|currently on disability|currently employed |currently retired|"] _______________________________________________________________________________ FAMILY MEDICAL HISTORY: Medical: [textarea name="freefhx" default="|Patient denies a family history of diabetes, cancer, thyroid issues, heart disease, hypertension, lung diseases, kidney problems, genetic disorders, stroke, MSK disorders, neurological disorders"] Psych:[textarea name="psychfmh" default=""] Substance Use:[textarea name="sudfmh" default=""] _______________________________________________________________________________ HISTORY OF COMMUNICABLE DISEASES: •Patient [select name="std" value="denies|endorses|does not disclose"] current concerns about STDs and Hep C •History of MRSA/VRE: [select name="MRSA" value="no|yes|unknown"] •History of TB: [select name="TB" value="no|yes|unknown"] •COVID SCREENING: Denies fever, fatigue, cough, SOB, chest pain, diarrhea, and sick contacts. No recent travel outside state or to foreign countries. VACCINE STATUS: COVID: [select name="COVID" value="yes|no|unknown"] Influenza: [select name="flu" value="yes|no|unknown"] _______________________________________________________________________________ ROS: 12-point system reviewed; Pertinent negatives and positives discussed in HPI. _______________________________________________________________________________ PHYSICAL EXAMINATION GENERAL: well-appearing, cooperative, well-nourished, in NAD DERM: No open wounds or abrasions. Skin warm and dry. Capillary refill in fingers <2 seconds. HEAD: Normocephalic, atraumatic. EENT: PERRLA, EOMI, pupils 3mm, sclera and conjunctiva without erythema or injection. Vision grossly normal and gaze aligned appropriately, oral mucosa and gums pink and moist, no pharyngeal or tonsillar exudate, uvula midline. No sinus tenderness. No dental abscesses seen. Unable to assess: EACs & Bilateral TMs. NECK: supple CV: RRR, S1 & S2 clear, without m/r/g. No peripheral or generalized edema. +2 pulses in upper and lower extremities. RESP: lung fields clear bilaterally. Respirations even and regular. No use of accessory muscles. Air entry normal. GI: Soft, non-tender, non-distended. BS present x 4. No masses. No hepatosplenomegaly. GU: No bladder distention. Genital exam deferred r/t asymptomatic. MSK: Bilateral upper/lower extremities: symmetric, adequate muscle tone with 5/5 muscle strength, full ROM. No CVA tenderness. NEURO: A & O x 3. Stable gait and coordination. CN II-XII intact. Patellar Reflexes: 2+ bilaterally, bilateral normal sensation to all extremities PSYCH/MSE: --General/Appearance: [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed| appears stated age| appears older than stated age| appears younger than stated age"]. --Sensorium:[select name=_variable_2_ value=_alert and oriented in all spheres|obtunded|disoriented|disoriented|fatigued] --Behavior - general: [select name="variable_4" value="in no acute distress|in acute psychological distress"]. --Behavior - stability: [select name="variable_5" value="calm|agitated|neutral"]. --Behavior - interactivity: [select name="variable_6" value="polite and cooperative|interactive|withdrawn|hostile|questioning|demanding|agitation present"]. --Behavior - eye contact: [select name="variable_7" value="eye contact good|eye contact fair|eye contact avoidant"]. --Mood/Affect: [select name="variable_8" value="normal|upbeat|euthymic|depressed|dysthmic|neutral|anxious|hostile|irritable|tearful"]. --Mood/Affect - emotional range: [select name="variable_9" value="normal|broad|restricted"]. --Mood/Affect - intensity: [select name="variable_10" value="normal|expansive|blunted|flat"]. --Mood/Affect - congruence: [select name="variable_11" value="mood is congruent with affect|mood and affect are not congruent"]. --Thought form and content: [select name="variable_12" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned|tangential|circumstantial"] --Attention: [select name="variable_13" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"]. --Perception - insight: [select name="variable_14" value="normal insight|poor insight"] --Perception- general: [select name="variable_15" value=normal|normal - denied any preoccupations, obsessions, delusions, mania, hallucinations or perceptual disturbances| abnormal- endorses preoccupations, obsessions, delusions, mania, hallucinations or perceptual disturbances| observed preoccupations, obsessions, delusions, hallucinations, mania or perceptual disturbances"] --Cognition/Memory: [select name="variable_16" value="normal|grossly intact|below average|above average|abnormal|deterioration"]. --Cognition/Memory - abstraction: [select name="variable_17" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"] --Judgment: [select name="variable_18" value="normal|poor|good"]. --Suicide/Assault: [select name="variable_19" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"]. _______________________________________________________________________________ LABS COLLECTED ON ADMISSION: CBC, CMP, TSH, UA, Urine Drug Screen [text name="labtest" default="Other tests:"] _______________________________________________________________________________ ASSESSMENT/PLAN Reason for Admission: This patient is here for voluntary admission for medically managed withdrawal and recovery. During this stay, this patient will be provided education and support during recovery in a protected environment. _______________________________________________________________________________ ACTIVE PROBLEMS/MEDICAL PLAN: 1.[checkbox name="sud2" value="alcohol use disorder|amphetamine use disorder|cannabis use disorder|sedative,hypnotic,anxiolytic use disorder| opioid use disorder| cocaine use disorder| other stimulant use disorder| hallucinogens use disorder| substance use of inhalants| substance use of other psychoactive substances and multiple drug use"] [checkbox name="continued" value="Continue [checkbox name="detoxdrug" value="Librum per protocol| Ativan per protocol|Suboxone per protocol| Valium per protocol| Ativan PRN per protocol"] - Monitor s/s for withdrawal - Provide PRN medications as indicated - Educate on the withdrawal process, detox protocol, medication management, and side effects - Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan - Coordinate treatment with the psychiatric team - Encourage to engage in ongoing relapse prevention and aftercare plan - Continue to monitor during detox and recovery in a protected environment - Pending labs for admission [checkbox name="nalt" value="[checkbox name="viv" value="Educated on naltrexone and vivitrol"] _______________________________________________________________________________ #.[checkbox name="nic" value="Nicotine Use Disorder"] [checkbox name="cess" value="[select name="variable_4" value="Cessation Date planned for stay. Behavioral options for quitting reviewed. NRT in place| Behavioral and Pharmacological options for quitting were reviewed. Does not wish to quit at this time"] _______________________________________________________________________________ #.[select name="HTN" value=" |Hypertension|Elevated BP without a dx of HTN"] [checkbox name="htnplan" value="Monitor vital signs daily. This patient is going through acute withdrawal from ETOH therefore pt blood pressure will be labile. (Goal for Blood Pressure is Blood pressure less than 60 year old less than 140 over 80 (with or without diabetes CKD) greater than 60 years old less than 150 over 90)"] [checkbox name="htnmed" value="Continue Medication"][text name="htnmed" default=" "] _______________________________________________________________________________ #.[comment memo="OTHER MEDICAL CONDITIONS-PLANS"] [textarea name="variable_MED" default=""] _______________________________________________________________________________ #.[comment memo="OTHER PSYCH CONDITIONS-PLANS"] [textarea name="variable_psychconplan" default=""] _______________________________________________________________________________ #.[select name="BMI" value=" |BMI"] [checkbox name="variable_bmi" value="Encourage moderate daily exercise and healthy eating habits (high water, fiber, and lean protein) (reduce caloric intake Women 1200-1500kcal/day men 1500-1800 day)drink non-sugar, non-caffeinated beverages|LAB ORDER: Glucose, Hemoglobin A1c, Total Cholesterol, HDL Cholesterol, Triglycerides, Non-HDL, and Calculated Components"] _______________________________________________________________________________ #. [select name="stdhr" value="||High Risk Sexual Behavior"] -[checkbox name="variable_stdhr" value="R/F include multiple partners, new partners, unprotected sexual encounters, known + partners|Testing for G/C (urine/ swab), HIV, Hep C, RPR, BV, Herpes (blood, swab)"] -[link url="https://www.mdcalc.com/denver-hiv-risk-score" memo="Denver High Risk Score"][text name="stdhr" default=" "] _______________________________________________________________________________ #. [select name="sxhx" value="||Seizure History"] -[checkbox name="variable_sxhxr" value="Medications Rx'd to aid with alcohol withdrawal seizures. Nursing to monitor CIWAs and Vitals. If a seizure were to occur then acute management of the seizure should be concomitant with ABCs, avoiding hazards, and monitoring vital signs & glucose monitoring. Nursing advised to call provider if this occurs; call EMS if decompensation occurs"] _______________________________________________________________________________ #. [select name="sxsicurrent" value="||Suicidal Ideation"] -[checkbox name="variable_sxsicurrent" value="Patient is determined to be at __risk for suicide. Interventions include daily monitoring of suicidal ideation and every 15-minute rounding for safety. Nursing advised to immediately contact the provider if there is an escalation in suicidality"] _______________________________________________________________________________ MEDICAL CLEARANCE: This patient is medically cleared to participate in therapeutic programming as tolerated. [textarea name="variable_1" default="If not, why"]CONTINUING PROBLEM LIST: [textarea name="PROBLEMLIST" default="It is recommended that this patient should establish care and/or follow up with PCP after discharge regarding health maintenance and preventative health guidelines for ages 19-64 years "]
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