SUD Admission Notes
HPI – Patient is a [text name="variable_1" default="sample text"] with alcohol use disorder who presents to Landmark Recovery for treatment. Pt reports first use of alcohol at the age of [text name="variable_1" default="sample text"]. Pt reports regular alcohol use by the age of [text name="variable_1" default="sample text"]. Pt reports they normally drink [text name="variable_1" default="sample text"] daily for [text name="variable_1" default="sample text"] and increased to [text name="variable_1" default="sample text"]. Last alcohol intake was[text name="variable_1" default="sample text"] and they drank [text name="variable_1" default="sample text"]. Pt also reports use of opiates. Pt reports first use at the age of [text name="variable_1" default="sample text"]. Pt reports regular use by the age of [text name="variable_1" default="sample text"]. Pt reports they normally take [text name="variable_1" default="sample text"] daily for [text name="variable_1" default="sample text"] and increased to [text name="variable_1" default="sample text"]. Last opiate intake was [text name="variable_1" default="sample text"]. In addition pt reports use of THC at the age of [text name="variable_1" default="sample text"]. Pt reports regular use by the age of [text name="variable_1" default="sample text"]. Pt reports they normally use THC [text name="variable_1" default="sample text"] for [text name="variable_1" default="sample text"] and increased to [text name="variable_1" default="sample text"]. Last intake was [text name="variable_1" default="sample text"]. In addition pt reports use of amphetamines at the age of ??. Pt reports regular use by the age of ?? Pt reports they normally use ?? daily for ?? and increased to ??. Last intake was ??. UDS results - Breathalyzer testing on admission - CIWA - COWS - PAWSS - The patient denies seizure associated with withdrawal and DT’s in the past. Negative impacts associated with substance includes Prior treatment hx includes Longest period of sobriety was The pt denies substance use of others in household The pt’s goal is to Past Psych Hx: History of psychosis: denies History of SI/HI: denies History of Suicide attempts: denies History of psych hospitalization: denies History of trauma: denies History of self harm: denies Pt endorses symptoms of depression: Pt endorses symptoms of anxiety: Pt endorses symptoms of past trauma: Medical Hx: Surgical Hx: Family: Mom- No SUD, Dx/healthy Dad- No SUD, Dx/healthy Social: Support system: Who do you live with: Marital status: Number of children: Employment: Tobacco use Education: Miliary History: Legal issues: Medications: Allergies: ROS (pertinent negatives and complaints) Constitution- denies weight loss, fever, chills, malaise Neuro- denies dizziness, confusion, headache syncope Psych- denies recent changes in mood, anxiety, depression, SI, HI, and psychosis ENT- denies changes in hearing. Denies sore throat and lymphadenopathy Eyes- denies visual disturbances, discharge, and double vision Resp- Denies SOB, cough, and hemoptysis CV- Denies palpitations, flutter, and chest pain MS- Denies difficulty with ambulation, myalgia and joint pain and swelling Gi- denies nausea, vomiting, recent change in bowel habits, and abdominal pain Gu- Denies dysuria, urinary retention, and incontinence Skin- Denies wounds, rashes, itching and erythema Physical Skin: free of abscesses, sores, bruises, rash, swelling HEENT: conjunctiva pink sclera white without jaundice, throat non-erythematous, nares patent Neck: Full ROM, no JVD, trachea midline Resp: even/non labored Cardiovascular: cap refill < 3 seconds, no noticeable bounding pulse, normal heart rate Abdominal: no guarding, non-distended, self palpation - soft nontender Extremities: full ROM GU/Rectal: deferred Neuro: A&O x 3, no aphasia, gait normal, Romberg negative MS: no muscle wasting, full ROM PLAN: Alcohol Use Disorder – pt will be admitted to detox LOC for withdrawal management. PAWSS score 4 - Frontload Valium 10 mg q6 hrs for 24 hours. Continue CIWA protocol with Ativan. Continue CIWA protocol. Discussed anti-craving medications (naltrexone and campral). Opioid Use Disorder Continue COWS protocol. For a COWS score 10 or greater, give 4 mg buprenorphine once, and again in 6 hours if needed for continued score 10 or greater for a total of 2 x doses. Facility to continue COWS treatment. Hyperthyroidism An accurate dose of Synthroid was not established. Will defer to facility to f/u with PCP for accurate dose. Nutrition The pt will be encouraged to eat 3 meals a day while she is admitted. Encouraged pt to attend and participate in all therapy sessions. Order admitting labs: CBC w diff, CMP, RPR D/c planning: social work to follow, has a safe place to return to PT HAND OFF GIVEN TO:
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