-Chief Complaint: “i feel bad”
History of Present Illness:
Patient is a 59 year old male with PPHx of alcohol use disorder, MDD, and PMHx of DVTs, PE, and BPH who was admitted to for medical stabilization of acute cholecystitis. psych consulted for mgt of depression and AUD.
Patient seen today seen at bedside, meds, labs and chart reviewed. Upon evaluation today, pt states mood is “not good” and reporting stomach pain, nausea, anxiety, HA; Denies hx of DTs or SZ in the past, but c/o moderate etoh withdrawals. states after HRC detox in 10/2023, pt was in rehab for 90 days and did well; was sober. he went to a sober home after but didnt like the rules so he left after a week. he relapsed immediately. has been street homeless and subsequently developed feelings of hopelessness and worthlessness. He has poor social support – all his family members are deceased except for 1 son, though they are estranged. He is not on psychotropic medication. states he did not follow up with outpt tx and psychotropic rx. states when he was taking his rx he did well. He interested in restarting psychotropic medications for mood. per chart review was last on fluoxetine 10mg He denies any sxs of psychosis, mania, adamantly denies any active suicidal thoughts nor death wishes, intent or plan. He is agreeable to go to Rehab program.
Outpatient: nonadherent
Compliance: intermittent
Hospitalizations: multiple for alcohol detox/withdrawal, most recent HRC 03/2022
State Hospitalizations: denies
Suicide Hx: denies
SUBSTANCE USE HISTORY
Etoh: endorses daily use of 1L vodka daily
Drugs: denied
Detox: multiple times
Rehab: endorses, previously at Camillus House
Smoking Status
Current everyday tobacco user
PAST MEDICAL HISTORY
see chart
FAMILY HISTORY
Medical: Father: Cancer of colon; Hypertension
Psychiatric disorders: denied
Alcohol/Substance use disorder: denied
Suicide or suicide attempts: denied
PSYCHOSOCIAL HISTORY:
Born in Puerto Rico
family members deceased
divorced, 1 son
Legal: Denied
Employment: Unemployed, receives disability checks
Living situation: Homeless
-Hx of trauma: No
Patient appearance: appears stated age, fairly groomed, good hygiene
Behavior: calm, appropriate
Attitude: cooperative
Eye contact: fair
Motor function: no psychomotor agitation + tremors or retardation
Orientation: person, place, time, situation
Speech: normal rate/tone/volume
Mood: “better”
Affect: mood congruent, euthymic
Thought Process: organized
Thought Content:
Delusions: None
Perceptual disturbances: None
Insight: fair
Judgment: fair
Attention: attentive
Concentration: intact
Diagnoses
Thrombocytopenia, unspecified (D69.6)
Alcoholic cirrhosis of liver without ascites (K70.30)
Abnormal levels of other serum enzymes (R74.8)
Alcohol dependence, uncomplicated (F10.20)
Epigastric pain (R10.13)
End of Diagnoses List
Psychiatric Consult Recommendations:
Patient is a 59 year old male with PPHx of alcohol use disorder, MDD, and PMHx of DVTs, PE, and BPH who was admitted to for medical stabilization of acute cholecystitis. psych consulted for mgt of depression and AUD. now facing uncomplicated withdrawal and mild depressive symptoms. Not a danger to self or others. In need of detox and treatment for alcohol use disorder as below.
Medication recommendations:
-Continue Ativan taper, until discontinue.
-Continue rally pack, with MTV, folic acid 1mg and thiamine 100mg qd
-restart Fluoxetine 10mg qd
-can consider restarting naltrexone 50mg po daily for alcohol use disorder – provide Rx at discharge. Pt has not used opioids during the last week.
Labs/Imaging recommendations:
As per primary team
Monitor LFTs .
Safety
-At risk of harm to self or others: No
-Needs 1:1 sitter: No
-Requires video monitoring: No
-Baker Act status: Lift
-Marchman act status: No – pt requesting voluntary treatments
Precautions:
-Fall risk: Yes
-Seizure: Yes during withdrawal
-Elopement: No
-Suicide: No
-Substance use withdrawal: Yes monitor CIWA
Other consults recommended:
-Social work assistance? Yes, discharge planning and community resources for shelter, rehab programs and AA meetings.
Disposition:
-Need transfer to psychiatry inpatient? No.
Patient does not meet criteria for Baker Act, involuntary hold, or inpatient psychiatric hospitalization. Disposition as per primary team, social work to assist once detox is completed and pt is medically stable.
