Substance abuse

Students must post one interesting case that he/she has seen in the clinical setting via Discussion Board in the online part of this course. The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan. Notes will be graded as “pass/fail”. In order to receive grade points for SOAP notes, the notes must be approved by the deadlines specified on the course assignments page. The student will lose the opportunity for points on any SOAP notes not approved by the specified deadlines. The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years.

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Sample of a SOAP note below:

HPI:
Patient is a 78-year-old man who live insist that use sunblock he walks a lot outdoors and has a very significant and on his arms with a dryness and arms also.
He presented with cough. chest. The symptom started few days ago. It is described as intermittent. Frequency is daily. The complaint is ongoing. Smoking status: Never smoker
Alcohol consumption: Never consumed
Substance abuse: Never consumed
Active Medications:
Atenolol (25.00000 – mg), take 1.00 tablet by mouth once a day
Lovastatin (40.00000 – mg), take 1.00 tablet by mouth once a day
Pantoprazole sodium (40.00000 – mg), for 90 days,
Tramadol hcl (50.00000 – mg), take 1.00 tablet by mouth twice a day
Allergies: He has no active known allergies.
Review of History:
Past surgical:
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance, Last performed on 10/02/2013.
Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or ct) including arthrography when performed. Colonoscopy, flexible; with biopsy, single or multiple Last performed on 10/20/2010.
Complex uroflowmetry (eg, calibrated electronic equipment), Last recorded on 08/26/2010.
Voiding pressure studies (vp); bladder voiding pressure, any technique. Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging, Last recorded on 08/26/2010.
Cystourethroscopy (separate procedure), Last performed on 08/03/2017.
Biopsy, prostate; needle or punch, single or multiple, Last recorded on 07/02/2014.
Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level.
Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (list separately in addition to code for primary procedure).
Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification).
Reviewed the following past medical:
Essential (primary) hypertension.
Constipation, unspecified.
Gastro-esophageal reflux disease without esophagitis.
Benign prostatic hyperplasia without lower urinary tract symptoms. Barrett’s esophagus without dysplasia.
Hematuria, unspecified.
Elevated prostate specific antigen [psa].
Benign prostatic hyperplasia with lower urinary tract symptoms.
Ventral hernia without obstruction or gangrene.
Social History:
He is married, never smoker, has never consumed alcohol, is a current every day consumer of coffee or tea, is not a substance abuser, has a Dairy Free diet, follows a balanced diet, has sufficient rest or recreation, does not have a risky sexual behavior, does not have disabilities, does not have family stress, does not have job stress, does not do physical exercise,has living arrangements: Private Residence with Family.
Family History: His family presents the following diseases: his Mother has Heart disease (high blood pressure), his Father has Heart disease (heart).
ROS:
Eyes: The patient denied change in vision, eye pain, redness, discharge.
Ears, Nose, Mouth, Throat (ENT): The patient denied loss hearing, congestion, sinus pain, change in hearing, ringing in ears (tinnitus), frequent nose bleeds (epistaxi), sore throat, hoarseness, ear pain, pain in throat.
Respiratory: The patient complained of cough, but denied wheezing, hemoptysis, phlegm.
Cardiovascular: The patient denied chest pain, palpitations, dyspnea, orthopnea, shortness of breath, hypertension.
Gastrointestinal: The patient denied acidity, gastritis, flatulence, hiccups, abdominal pain, difficulty swallowing(solids vs liquids), bloating, nausea, diarrhea, constipation, bright red blood per rectum (BRBPR,hematochezia), vomiting_, change in bowel habits, hemorrhoids. GU/Gyne/0B: The patient denied dysuria, hematuria, incontinence, pain with urination, cloudy urine, rectal discomfort.
Musculoskeletal: The patient complained of pain. Left Hip Pain, but denied wound, swelling (edema), tenderness, weakness, areas of numbness. Neurological: The patient denied dizziness, faints, headache, numbness, limb weakness, tremor, memory loss.
Psychiatric: The patient denied depression, anxiety, insomnia, suicidal thoughts.
Endocrine: The patient denied – diabetes mellitus, hair loss, heat or cold intolerance, change in facial or body hair, cfange in weight. lnteg.urnentary (skin and/or breast): The patient denied itching, change in moles, dry skin, ecchymosis, onychomycosis, lesion, abscess, rash. Hematologic/Lymphatic: The patient denied anemia, easy bruising, tender or palpable lymph nodes.
Allergic/Immunologic: The patient denied other reactions, sneezing, runny nose, post nasal drip.
Constitutional: The patient denied fever, weight loss, weight gain, night sweats, fatigue/malaise/lethargy.

 

Vital Signs: Weight: 176 lb O oz. Height: 5 ft 8 in.
Pulse: 64 bpm. Pulse: Normal, interpretation: Normal
Blood Pressure: 140/70 mmHg. Location: Left Arm. Position: Sitting. Temperature: 97.6 degrees F. BMI: 26.8 kg/m2. Respiratory rate: 16 bpm.
PE: Constitutional: Overall: Alert, cooperative.in no distress.appears stated age. Development: well developed. Nourishment: well nourished. Eyes: Eye: Conjunctivae and sclerae are clear without icterus.Pupils are reactive and equal..
Ears, Nose, Mouth, Throat (ENT}: Head: Normocephalic, without obvious abnormality,atraumatic .. Ears: Normal external ear canals, both ears .. Nose: mucosa normal no drainage.bleeding .. Throat: Lips mucosa , and tongue normal; teeth and gums normal. Neck: Supple,Symmetrical,trachea midline,no adenopathy,no carotid bruit or JVD. Thyroid gland: normal. Mouth: Lips mucosa , and tongue normal; teeth and gums normal. Cardiovascular: Pulse: regular. Blood pressure: normal. Auscultation: murmur. I/VI SEM.
Respiratory: Chest and Lungs: Clear to ascultation bilaterally, respiration unlabored,no wheezing, rales or crackles ..
Gastrointestinal: Abdomen: hernia. Huge midline hernia Stable. Rectal: deferred. GU/Gyne/OB: Genitalia: deferred.
Musculoskeletal: Hip: pain. Left Hip pain in scale 1 -10 reports 7. Upper extremities: normal atraumatic, no cyanosis or edema. Lower extremities: normal atraumatic, no cyanosis or edema.
lntegumentary (skin and/or breast): Skin: Skin color,texture,turgor normal.no rashes,or lesions .. Nails: normal.
Neurological: Cranial nerves: Cranial Nerves II-XII appears intact. Motor: normal. Coordination and Gait: Alert,Oriented. Reflexes: Strength normal. Sensory: Alert.Oriented,
Psychiatric: Orientation to time, place and person: normal. Recent and remote memory: normal. Mood and affect: No distress,mood looks normal,no agitation,no hallucinations.
Hematologic/Lymphatic: Groin: normal. Other: Cervical, supraclavicular and axillary nodes normal.
Chest / Breast: Breasts: normal.
Assessments:
Essential (primary) hypertension.
Cough.
Body mass index (bmi) 26.0-26.9, adult.
Plan:
Follow up on 1 month
Kenalog 40 mg IM,
Zithromax Z Pack
Cholesterol diet – deeply colored fruits and vegetables, fiber rich grain products, fat-free products, 1 percent and low fat milk products, lean meats and poultry without skin, fatty fish, nuts, seeds, an legumes(dried beans or peas), and unsaturated vegetable oils ..
Patient Education: She received verbal educational instructions for All the questions was answered and understood, breast self exam, Call or Return if Symptoms worsen or persist, Depression Screening Performed today, Discussed Bowel and Bladder Control, Fall precautions and Accident prevention, I Discussed all treatment options with the patient, Reviewed all Current Medications, seat belt, Skin protection, stress

 

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substance abuse

I don’t know how to handle this History question and need guidance.

38 y/o male

HISTORY OF PRESENT ILLNESS:

A 38 y/o male was sent to psychiatry directly from his internist’s office.That morning the pt. and his wife presented to the doctor’s office without an appointment, and the pt. expressed feelings of being overwhelmingly depressed.He had developed a plan to commit suicide, which included taking a bottle of Tylenol and drinking “as much vodka as it takes”. The internist performed a thorough evaluation, drew labs and called 911 to have the patient brought to the ER.

When you encounter the pt., he is visibly upset and clinging to his wife. The couple explains that they separated a month ago, because the patient “just couldn’t be a husband anymore”.

Over the past 6 weeks he has become isolative, complained of decreased energy, concentration, appetite, and sleep.He had lost his job as a house painter 6 months earlier.The patient no longer enjoyed the caretaking of the couple’s 2 children, ages 4 and 6—a drastic change from the role he had previously enjoyed as a father.

You ask the patient when he first began feeling down.He states clearly, “When my mother died, one and a half years ago.”He said that he had been feelingguilty over the circumstances of her death and wishing he had been closer to her in the years preceding her death.The wife notes with concern: “That was just anbout the time you started drinking so heavily, as well.”As you question further, you determine that the pt. has been drinking daily since his mother’s death.He estimates that he is drinking 6 beers a day.He admits that drinking is a problem, and he actually tried to stop drinking two weeks before this visit.The patient said:“My wife kicked me out of the house, I missed my kids, I didn’t have a job…I knew something was wrong.”He noted that in the days after stopping drinking, he experienced some shakiness and symptoms “like there were bugs under my skin.”He added that having a beer made these symptoms subside.Last night he had become very upset after calling his wife to check on the children and finding they were not at home.He sat in his hotel room and thought, “I can’t go on living like this.”He called his wife at 6 am the next day and said he thought he might kill himself.She immediately brought him to the internist’s office.

PAST PSYCHIATRIC HISTORY:

The pt. has never been psychiatrically hospitalized, nor has he seen a psychiatric provider before.He recalls having been depressed only once earlier in his life, during his 20’s, but he did not seek treatment at that time.Although the pt. is currently suicidal, he denies any past suicidal thinking and has never made previous suicide attempts.

PAST MEDICAL HISTORY:

HTN, Hypercholesterolemia.

MEDICATIONS:Metoprolol, 50 mg bid.

FAMILY HX:

The pts’s father has a hx of alcohol dependence, and his mother had HTN and coronary artery disease before dying of an MI.Pt. denies any Hx of psychiatric illness in his family.

SUBSTANCE ABUSE HX:

The pt has been drinking 6 beers/day for the past year and a half; before that he was not drinking on a daily basis.He has a remote history of similar drinking in his 20’s during his first divorce, but he was able to quit “cold turkey” and has never been to any detox. facility.He experienced symptoms of with drawl when he quit but has no history of withdrawal seizures.He denies use of marijuana, heroin, cocaine, or other substances.He smokes ½ pk per day of cigarettes.

SOCIAL HISTORY:

The pt describes a chaotic childhood, since his father was ‘

“unpredictable” because of his drinking.He finished high school and then went to vocational school.He became a house painter and worked sporadically.He was married in his early 20’s and has a 17 y/o daughter who is being raised by her mother.He married his current wife 8 yrs. Ago; the marriage was functioning well until the recent became a problem.

MENTAL STATUS EXAM:

The pt. is a white male who appears exhausted and mildly disheveled in a sweatshirt, baseball cap, and jeans.He frequently becomes teary throughout the evaluation and has poor eye contact, although he is cooperative with the interview.His stature is slumped, even seated in the chair, and he often leans forward and hides his face in his hands.His speech is notable for increased latency and paucity of words.His affect is dysphoric, congruent with the context of the discussion, and does not brighten throughout the interview.His thought process is linear and logical, and thought content is preoccupied with his mother’s death.The pt. has no overt delusions, he denies ideas of reference and paranoid ideation.He also denies hallucinations.He is experiencing suicidal ideation with intent and plan but denied homicidal ideations.

His insight and judgment are fair at this moment in that he knows he needs treatment.Cognitive exam is grossly intact.

LABS:

Alcohol level= 130; AST = 68 IU/L; ALT = 45 IU/L; GGT= 35U/L; other liver function tests are WNL.

Hemoglobin =13.4; hematocrit = 41; MCV =95; triglicerides = 200 mg/dl.

Include:

  • Any differential diagnoses
  • Your diagnosis and reasoning
  • Any additional questions you would have asked
  • Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
  • Any labs and why they may be indicated
  • Screener scales or diagnostic tools that may be beneficial
  • Additional resources to give (Therapy modalities, support groups, activities, etc.)