| Criteria | Clinical Notes |
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| Informed Consent | Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) |
| Subjective | Verify Patient Name: AA DOB: 5/15/02 Minor: N/AAccompanied by: none Demographic: Patient is a 20-year-old Caucasian male brought to facility by family member from home in Eastern United States. Patient presents for treatment related to substance abuse and is voluntarily admitted. Patient owns own home and works full time. Was living with girlfriend until three weeks ago. Graduated high school and attended trade school for one year for welding. Has no children and is unmarried. Reports having a supportive family consisting of mother and several cousins. Denies having a social circle or supports. Gender Identifier Note: Male CC: “I’ll die out there without help”. HPI: : Patient reports beginning substance abuse in the last three weeks following the discovery of his longtime live-in girlfriend’s infidelity with one of his male family members. Indicates he “went off the rails” and began taking non-prescribed opiates and benzodiazepines. Indicates he has been taking around seven tablets of Norco 5/325 daily and three Xanax “bars” (2 mg tablets) per day for approximately three weeks. Reports last use of Norco and Xanax 36 hours ago. Patient denies use of opiates and benzodiazepines in the past. Patient indicated he has smoked marijuana regularly since the age of 17 and takes several “hits” daily. Reports he smokes a full joint, around one gram, every week. Patient reported he uses marijuana to reduce anxiety. Reports last use of marijuana 12 hours ago. Patient reports he has been unable to stop his use on his own; is failing to meet obligations with work and at home; is engaging in dangerous behavior, such as driving under the influence; is not attending to activities of daily living; spends significant time attempting to obtain or recover from use; reports having cravings; and describes tolerance as manifested by needing to take substances more frequently or in greater amounts to obtain desired effect and experiencing withdrawal symptoms when unable to obtain substances. Denies other substance use. Patient indicated he feels depressed, reporting intermittent tearful episodes, bursts of anger, feelings of guilt, shame, and worthlessness and has attempted suicide three times in a three-week span. Reported he has access to numerous firearms including rifles and shotguns used for hunting and pistols used for personal protection and sport. Indicated his first attempt occurred within days of his discovery and he put a pistol to his head. He reports his girlfriend talked him out of shooting himself, but he reports discharging the weapon twice in the room, shooting the bed and dresser mirror. His second attempt was via overdose the following week and reports having taken around 60 quantity of buspirone of unknown dosage. He indicated this made him drowsy and unable to move, and he reports not seeking medical assistance when regaining his faculties. The third attempt involved homicidal ideation in which the patient waited in the woods with a shotgun for the accused male family member to return home at which point he planned to commit a murder-suicide with that weapon. Patient stated, “the only reason I’m alive is because he didn’t come home”. Patient continues to report suicidal ideation with intent and plan to shoot himself, as well as a plan to murder the male family member first. Pertinent history in record and from patient: yes During assessment: Patient describes their mood as poor and indicated it has gotten worse in three weeks. Patient self-esteem appears poor, reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does report decrease in appetite, does not report libido disturbances, does not report change in energy,no reported changes in concentration or memory. Patient does report increased activity, denies agitation, denies risk-taking behaviors, denies pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature. SI/ HI/ AV: Patient currently reports suicidal ideation, denies SIBx, reports homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors. Allergies: NKDFA.(medication & food) Past Medical Hx: Medical history: Patient reports he has no chronic medical conditions. Acute illnesses have included a broken right femur related to a sports injury at 15 years old and several incidences of strep throat. Reports received a tonsillectomy at age seven. Denies other surgical history. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.Surgical history tonsillectomy age 7 Past Psychiatric Hx:Previous psychiatric diagnoses: diagnosis of PTSD, depression, and anxiety.Describes deteriorating course of illness. Previous medication trials: unknown at this time.PTSD: Patient reported extensive emotional and physical abuse by his father “for as long as I can remember”. Indicated he was left with him periodically by his mother and, while intoxicated, the father would strangle him to the point of losing consciousness. He reports also witnessing his father beat several women “into a bloody pulp”. Reports he startles easily at the sound and sight of men and has become physically aggressive at work when a male coworker startled him. He reports punching the man in the face and breaking his jaw. Anxiety: Patient reports significant social anxiety and stated this began in middle school. Reported that he struggles with leaving the house, experiences panic attacks which he describes as intense shaking and rapid breathing and has thoughts that “won’t shut off”. Patient reports he has taken paroxetine and buspirone in the past but cannot recall the dosage of either medication. Indicated was not taking buspirone regularly and believes prescription was outdated. Cannot recall when he last took paroxetine and believes it was prescribed when he was 18 years old. Indicated he trialed it for around six months and found it to be ineffective. Reported he refused to trial additional medications. Depression: Patient reports feeling depressed for three weeks. Indicated he has not been able to sleep in their formerly shared bed and has been attempting to sleep in his truck. Reports sleeping one to two hours per night. Indicated he no longer has an appetite and reports feeling nauseous when eating. Indicated he no longer finds joy in any activities and lacks the motivation to go to work, reporting feeling “my rage is the only thing keeping me going”. Denies having sought treatment for depression or having experienced other episodes prior to this occurrence. Safety concerns: History of Violence to Self: three previous suicide attempts, see HPI for further detailsHistory of Violence to Others: attempted, see HPI for further details Auditory Hallucinations: deniesVisual Hallucinations: denies Mental health treatment history discussed: History of outpatient treatment: unknown at this timePrevious psychiatric hospitalizations: Unknown at this timePrior substance abuse treatment: Trauma history: Client reports abuse from father, see above for further details Substance Use: Client denies use or dependence on nicotine/tobacco products. Client reports opioid and benzodiazepine and cannabis use, see above for further details Current Medications: None at this time (Contraceptives): N/A Supplements: N/A Past Psych Med Trials: unknown at this time Family Medical Hx: Unknown Family Psychiatric Hx: Father:unknown diagnosis but was abusive Social History:Occupational History: currently employed full-time as a welder Military service History: Denies previous military hx.Education history: completed HS and vocational certificate Developmental History: no significant details reported. (Childhood History include in utero if available)Legal History: no reported/known legal issues, no reported/known conservator or guardian. Spiritual/Cultural Considerations: none reported. ROS:Constitutional: No report of fever or weight loss. Eyes: No report of acute vision changes or eye pain. ENT: No report of hearing changes. Patient indicated he has painful swallowing since the age of 9 following being strangled by his father. Cardiac: No report of chest pain, edema or orthopnea. Respiratory: Denies dyspnea, cough or wheeze. GI: No report of abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: No report of joint pain or swelling. Skin: No report of rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No report of blood clots or easy bleeding. Allergy: No report of hives or allergic reaction. Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…) |
| Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: , Past Medical and Psychiatric History,Current Medications, Previous Psych Med trials, Allergies. Social History, Family History.Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” |
| Objective | Vital Signs: StableTemp: Urine drug screen positive for opiates, benzodiazepines, and THC. Breathalyzer – 0.0COWS – 16Most recent vital signs: BP 162/98, HR 92, Temp 97.3, RR 18, O2 98% No blood work currently available. GAD-7: 13PHQ-9: 25 points Physical Exam:MSE:Patient appears disheveled and unkept. Hair is unclean and tangled. Patient is diaphoretic with a visible tremor. Patient noted to yawn several times in short succession. Patient noted to have watery eyes and runny nose. Skin is intact without bruises, abrasions, or open areas. Patient speech is tangential at times but able to be redirected. Limited insight and impaired judgement. Patient is cooperative. Patient mood is depressed and affect congruent. Patient noted to be picking at hangnails on several fingers throughout examination. Patient avoidant of eye contact. Patient noted to have motor retardation.Patient is oriented to person, place and time. Patient able to recall last five presidents. Patient able to learn and correctly recall three items. Patient able to recount a numeric sequence forward and backward without error.Exhibits intact immediate recall, short and long-term memory, concentration, attention, impulse control, and introspection. The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. |
| This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting)Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results. |
| Assessment | DSM5 Diagnosis: with ICD-10 codes Patient is suffering from opiate and benzodiazepine withdrawal and exhibits signs of major depression with suicidal and homicidal ideation. Patient meets DSM-V criteria for: opiate use disorder, severe (F11.20); Patient reports the past three weeks daily use of Norco 5/325 with 7 tablets per day. Last use was 36 hours ago. Patient reports he has been unable to stop his use on his own; is failing to meet obligations with work and at home; is engaging in dangerous behavior, such as driving under the influence; is not attending to activities of daily living; spends significant time attempting to obtain or recover from use; reports having cravings; and describes tolerance as manifested by needing to take substances more frequently or in greater amounts to obtain desired effect and experiencing withdrawal symptoms when unable to obtain substances. Per objective observation patient has physical symptoms of withdrawal with diaphoresis, watery eyes and runny nose, and tremors. There is motor retardation as well. According to guidelines from the American Society of Addiction Medicine (ASAM, 2020) pharmacology treatment options include methadone (mu agonist) for withdrawal management and treatment, buprenorphrine (partial mu-agonist) for withdrawal management and treatment, naltrexone (antagonist) relapse prevention, Naloxone (antagonist) for reversing an overdose, lofexidine (alpha-2 adrenergic agonist) for withdrawal management, and clonidine (alpha-2 adrenergic agonist) for withdrawal management. Cognitive Behavior Therapy (CBT) has strong evidence of being beneficial for those with substance use disorders as well as Motivational Interviewing (Carroll & Kiluk, 2017; Ingersoll, 2022). anxiolytic use disorder, severe (F13.20); Patient reports three Xanax “bars” (2mg tablets) daily for three weeks with last use 36 hours ago. Patient reports he has been unable to stop his use on his own; is failing to meet obligations with work and at home; is engaging in dangerous behavior, such as driving under the influence; is not attending to activities of daily living; spends significant time attempting to obtain or recover from use; reports having cravings; and describes tolerance as manifested by needing to take substances more frequently or in greater amounts to obtain desired effect and experiencing withdrawal symptoms when unable to obtain substances. Evidence of withdrawals from observation of diaphoresis, tremors. Treatment of withdrawal typically consists of slowly reducing dosage, carbamazepine (Tegretol) or Phenobarbital taper may be beneficial as well (Sadock et al., 2015). Close monitoring in the hospital may be warranted due to increased risk of seizures (Sadock et al., 2015). Cognitive Behavior Therapy (CBT) has strong evidence of being beneficial for those with substance use disorders as well as Motivational Interviewing (Carroll & Kiluk, 2017; Ingersoll, 2022). cannabis use disorder, severe (F12.20); Patient indicated he has smoked marijuana regularly since the age of 17 and takes several “hits” daily. Reports he smokes a full joint, around one gram, every week. Patient reported he uses marijuana to reduce anxiety. Reports last use of marijuana 12 hours ago. Patient reports he has been unable to stop his use on his own; is failing to meet obligations with work and at home; is engaging in dangerous behavior, such as driving under the influence; is not attending to activities of daily living; spends significant time attempting to obtain or recover from use; reports having cravings; and describes tolerance as manifested by needing to take substances more frequently or in greater amounts to obtain desired effect and experiencing withdrawal symptoms when unable to obtain substances. Treatment of cannabis abuse is similar to other substances. Support from family and treatment teams are encouraged (Sadock et al., 2015). Cognitive Behavior Therapy (CBT) has strong evidence of being beneficial for those with substance use disorders as well as Motivational Interviewing (Carroll & Kiluk, 2017; Ingersoll, 2022). Major Depressive Disorder, severe, single episode (F32.2); Patient reports symptoms of depression for greater than 2 weeks, anhedonia, sleep difficulties, amotivation, decreased hunger. He presents with a disheveled look, sad affect and reported mood. Treatment include medication management, typically starting with an SSRI such as sertraline (Zoloft) or citalopram (Celexa). SNRI’s are indicated as well such as venlafaxine (Effexor) or duloxetine (Cymbalta). Additional medication management therapies may be indicated as assessment continues such as addition of low dose aripiprazole (abilify) (Sadock et al., 2015). Psychosocial treatments include CBT, interpersonal therapy, and family therapy (Sadock et al., 2015). Anxiety, unspecified (F41.9). Patient has a history of social anxiety and panic attacks with symptoms of shaking, rapid breathing, and thoughts that “don’t’ shut off”. He was observed to be picking at his nails throughout the appointment. Some treatment options would include start of an SSRI such as paroxetine (Paxil) or the above mentioned medications (Sadock et al., 2015). Buspirone (Buspar) is another option to consider along with therapies such as CBT (Sadock et al., 2015). Differential Diagnoses:Agoraphobia – related to patient’s report of being anxious around others, especially in crowds at school, feeling trappedCyclothymia – given the patient’s recounting of past trauma and limited description of happiness and functioning independently, this may be an appropriate diagnosis. Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.Assessed for risk factors for suicide: History of impulsivitySuicide Protective Factors: Actively making future plans, verbalizes hope for the future, has responsibility to family and significant other, has belief that suicide is immoral (religious, particularly Christian), hopeful that current treatment is effective, taking steps to engage in treatment.There is no evidence of acute risk for harm to self or others. |
| Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability |
| Plan (Note some items may only be applicable in the inpatient environment) | Inpatient: Safety Risk/Plan: Patient is found to be unstable and has questionable control of behavior. Patient likely poses a high risk to self and a high risk to others at this time. Patient denies abnormal perceptions and does not appear to be responding to internal stimuli. Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: Referral will be made to case management for a duty to warn per facility protocol. Patient to create safety contract with therapist. Patient to be placed on 72-hour hold. COWS assessment every four hours for five days r/t detox. Medications:Fluoxetine 20 mg PO daily for depressionOlanzapine 10 mg PO QHS for depressionBuspirone 10 mg PO TID for anxietyPhenobarbital taper for benzodiazepine withdrawal as follows: 60 mg PO x 1 day, 30 mg PO BID x 2 days, 15 mg PO BID x 3 daysSubutex titration for opiate withdrawal as follows: 2 mg SL every two hours not to exceed 8 mgSubutex taper for opiate withdrawal as follows: 8 mg SL BID to begin x 2 days, 6 mg SL BID x 1 day, 4 mg SL x 1 day, 2 mg SL x 2 daysRobaxin 1500 mg PO every 8 hours PRN for muscle pain. Bentyl 20 mg PO every 6 hours PRN for abdominal crampingColace 100 mg PO BID PRN for constipationIbuprofen 600 mg PO every 6 hours PRN for painMultivitamin 1 tablet PO daily for nutritional supplementOndansetron 4 mg PO every 6 hours PRN for nausea Education, including health promotion, maintenance, and psychosocial needsPatient will be educated about medication regimen including indications and side effects and adverse reactions. Examples include metabolic effects of antipsychotic use, including weight gain, glucose resistance, and elevated triglycerides. Patient will also be educated about risk for gastrointestinal upset, sexual dysfunction, activation, and worsening suicidal ideation with initiation of antidepressant. Patient will be educated about potential for dizziness and headache with use of buspirone. Patient will be educated about timeframes for therapeutic effect, such as 1-2 weeks for olanzapine and 4-6 weeks for fluoxetine. Educated regarding phenobarbital is being used to help through withdrawals of benzodiazepines and will not be continued upon it’s tapered discontinuation. Subutex education provided regarding use for help with withdrawals. Continuation of this medication to be determined, notable side effects may include headache, constipation, nausea, orthostatic hypotension (Stahl, 2017).Safety planningLabs:CBCCMPHIV – rule outHep Panel – rule outFasting glucose – related to antipsychotic initiationLipid levels – related to antipsychotic initiationReferrals: Patient will be referred to therapy for Cognitive Behavioral Therapy for MDD and substance abuse. Encouraged participation in Narcotics anonymous and provided list of meeting places in the area. Interdisciplinary team will be notified of trauma history and need to announce self. Males suggested to remain outside of patient’s room. Follow-up TBD upon closer to discharge ☒ > 50% time spent counseling/coordination of care. Time spent in Psychotherapy 15 minutes Visit lasted 55 minutes Billing Codes for visit: 99204XX ____________________________________________ Date: 2/8/2022 Time: 1300 |
