Unspecified episodic mood disorder Other and unspecified alcohol dependence continuous Poisoning by opium (alkaloids) unspecified Accidental poisoning by other opiates and related narcotics Tobacco use disorder Asymptomatic human immunodeficiency virus [HIV] infection status Posttraumatic stress disorder Attention deficit disorder with hyperactivity
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: PSYCHIATRY
 
Allergies: 
E-Mycin
 
Attending: ___.
 
Chief Complaint:
"I don't know"
 
Major Surgical or Invasive Procedure:
none
 
History of Present Illness:
___ M with history of depression and polysubstance abuse 
brought
in by police after found intoxicated in the park.  At the time
the patient stated he took 6 tramadol as well, in an effort to
kill himself, though when sober, could only state "I don't 
know."
The patient is very vague throughout the interview but does say
that he has been feeling down lately and has " a lot of things 
on
my mind."  He notes that his mother is very ill and he is her
primary caregiver.  He also has been trying to stay sober, but
has been unsuccessful.  He denies any neurovegetative symptoms,
AVH, HI or paranoia.  When asked about SI, he just repeats "I
don't know" and when pressed further on whether he thinks he is
safe leaving the hospital he says, "I don't think so...I really
don't know."  He reports that he does not remember what happened
in the park today other than getting picked up by the police, 
and
he believes he took 6 or 7 tramadol.  He said this was for his
arthritis pain, but is not sure if he was also trying to kill
himself.
 
Past Medical History:
PSYCHIATRIC HISTORY: History of depression, polysubstance abuse, 
alcohol dependence, PTSD and ADHD (per the patient).  Multiple 
psychiatric admissions to ___, ___, ___, Deac 
4, (>5 per the patient) for SI/SA and detox.  The patient 
reports taking a bottle of Tylenol in ___, but cannot give any 
other history of suicide attempts. Per OMR, the patient has 
overdosed on cold tablets, soma + EtOH, and tried to drown 
himself in the ___ in ___. No history of 
assaultive behavior or HI. Current therapist: ___ at 
___.  No current psychiatrist

PAST MEDICAL HISTORY:
PCP ___ (ID) at ___: ___
-HIV pos since ___
-arthritis
-seasonal allergies
 
Social History:
SUBSTANCE ABUSE HISTORY: Currently
smokes < 1ppd, trying to quit.  He drinks 1 pint of vodka daily
for 2 days and then stops for a day and then goes back. Has
multiple detox's in the past, last at ___ a few months 
ago.
He was last sober in ___. No history of withdrawl seizures or
DT's.  The patient reports he last used cocaine "months ago" and
denies marijuana or other drug use.

SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):  The
patient says he moved frequently as a child with his mom and his
sister. He went to college in ___ and ended up
getting a MA in ___.  He worked many jobs 
until
___, when he started receiving SSDI.  He currently lives with
his friend ___ (___).  Has a history of sexual abuse
by his grandfather.  He reports that he's been arrested in the
past- his mother called the police and said she felt unsafe and
wanted a restraining order against him, which later dropped. 
 
Family History:
Mother- "something's going on"
Multiple distant relatives with completed suicide.
 
Physical Exam:
MENTAL STATUS EXAM (USE FULL, DESCRIPTIVE SENTENCES WHERE
APPLICABLE)
     APPEARANCE & FACIAL EXPRESSION: disheveled man with dried
blood over left eye wearing hospital gown
     POSTURE: lying in hospital bed
     BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS): no abnormal
movements
     ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): vague
     SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, 
ETC.):
normal in rate and prosody
     MOOD: "I don't know"
     AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.):
dysthymic
     THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
     CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): linear
     THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS,          

DELUSIONS, ETC.): Denies AVH, HI, paranoia. Vague SI, no intent
or plan.
         NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP,  

APPETITE, ENERGY, LIBIDO): none
     INSIGHT AND JUDGMENT: fair
     COGNITIVE ASSESSMENT:
          SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert
          ORIENTATION: oriented x 3
 
Pertinent Results:
___ 08:50AM   GLUCOSE-124* UREA N-15 CREAT-0.7 SODIUM-139 
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
___ 08:50AM   ALT(SGPT)-32 AST(SGOT)-32 ALK PHOS-92 TOT 
BILI-0.8
___ 08:50AM   CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.1
___ 08:50AM   TSH-1.0
___ 08:50AM   WBC-5.6 RBC-4.15* HGB-13.5* HCT-39.1* MCV-94 
MCH-32.5* MCHC-34.4 RDW-14.1
___ 08:50AM   PLT COUNT-278
___ 09:20PM URINE  HOURS-RANDOM
___ 09:20PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG 
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 09:20PM URINE  COLOR-Yellow APPEAR-Clear SP ___
___ 09:20PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 
LEUK-NEG
___ 02:00PM   GLUCOSE-90 UREA N-14 CREAT-0.6 SODIUM-143 
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-16
___ 02:00PM   estGFR-Using this
___ 02:00PM   ASA-NEG ___ ACETMNPHN-NEG 
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:00PM   WBC-5.8 RBC-4.62 HGB-15.0 HCT-44.0 MCV-95# 
MCH-32.5* MCHC-34.2 RDW-14.3
___:00PM   NEUTS-45.6* LYMPHS-49.3* MONOS-3.3 EOS-1.2 
BASOS-0.8
___ 02:00PM   PLT COUNT-___. Legal - The patient was transferred to Deac-4 on a ___, and was admitted on a CV.

2. Medical - The patient's only medical problem while on the 
unit was intermittent and persistent diarrhea.  Per patient, 
this is a chronic condition that his PCP is aware of, and that 
he experiences shame because of.  His PCP, ___ at 
___, was unavailable during the ___ hospital stay, and the 
tests ordered on the patient's stool were negative: C.diff 
(negative), viral (negative) and acid fast (pending) cultures.  
He complained of hip pain, which he reported as chronic and 
adequately controlled with motrin.

3. Psychiatric - Throughout his hospital course, the patient 
denied suicidal ideation.  He was continued on his home 
medications.  He was encouraged to attend and participate in 
groups, especially in the substance abuse/dual diagnosis group.  
He was monitored on a CIWA scale and did not show evidence of 
ETOH w/d.

 
Medications on Admission:
-Norvir 100mg daily
-Reyataz 300mg daily
-Truvada 200/300 daily
-Topamax 100mg daily
-Seroquel 100mg QHS
-celexa 40mg daily
-tramadol 50mg BID
 
Discharge Medications:
1. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY 
(Daily).  
2. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet 
PO DAILY (Daily).  
3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY 
(Daily).  
4. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a 
day (at bedtime)).  
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  
6. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) 
Spray Nasal BID (2 times a day) as needed for nasal congestion.  

8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 
 
9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times 
a day) as needed for diarrhea.  

 
Discharge Disposition:
Extended Care
 
Discharge Diagnosis:
AXIS I: ETOH Dependence, mood disorder NOS
AXIS II: Cluster B Traits
AXIS III: HIV, arthritis
AXIS IV: Problems related to chronic medical illness
AXIS V: 55

 
Discharge Condition:
Stable

O: vit- T 98.4, HR 69, RR 17, BP 108/70, Pox 100% RA
MSE: Patient is well groomed, appears stated age.  Has scars 
above L eyebrow.  Wearing casual clothes, and shorts.  Eye 
contact intermittently poor and intense.  Speech normal rate and 
volume.  Mood "good".  Affect labile.  TF: linear, TC: denies 
SI, HI, AVH.  I/J: fair, fair
 
Discharge Instructions:
1. If you are having thoughts of wanting to hurt yourself or 
others, please call ___ or come to the Emergency Department 
immediately.
2. Please continue to take your medications as prescribed.
3. Please keep all your appointments with your outpatient 
treaters as detailed below.
 
Followup Instructions:
___

{'feeling down': ['Unspecified episodic mood disorder', 'Other and unspecified alcohol dependence'], 'arthritis pain': ['Poisoning by opium (alkaloids)'], 'intoxicated': ['Other and unspecified alcohol dependence'], 'polysubstance abuse': ['Other and unspecified alcohol dependence', 'Tobacco use disorder'], 'suicidal ideation': ['Unspecified episodic mood disorder', 'Other and unspecified alcohol dependence'], 'seasonal allergies': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'history of depression': ['Unspecified episodic mood disorder'], 'PTSD': ['Posttraumatic stress disorder'], 'ADHD': ['Attention deficit disorder with hyperactivity']}