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:
HPI –

Patient is a with alcohol use disorder who presents to Landmark Recovery for treatment. Pt reports first use of alcohol at the age of . Pt reports regular alcohol use by the age of . Pt reports they normally drink daily for and increased to . Last alcohol intake was and they drank .

Pt also reports use of opiates. Pt reports first use at the age of . Pt reports regular use by the age of . Pt reports they normally take daily for and increased to . Last opiate intake was .

In addition pt reports use of THC at the age of . Pt reports regular use by the age of . Pt reports they normally use THC for and increased to . Last intake was .

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:

Result - Copy and paste this output:

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