Major depressive affective disorder recurrent episode unspecified Other and unspecified alcohol dependence continuous Posttraumatic stress disorder Malignant neoplasm of other specified sites of female breast Chronic hepatitis C without mention of hepatic coma Alcoholic cirrhosis of liver Asthma unspecified type unspecified
 
Name:  ___              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: PSYCHIATRY
 
Allergies: 
Penicillins / Sulfa (Sulfonamides)
 
Attending: ___
 
Chief Complaint:
"I need to stop drinking."
 
Major Surgical or Invasive Procedure:
Radiation therapy to left breast on ___ and ___ 
___.
 
History of Present Illness:
___ year old ___ woman brought herself to the ED for alcohol 
detoxification at the insistence of her outpatient psychiatrist, 
Dr. ___.  She reports that since she was diagnosed with 
breast cancer in ___ she has been feeling more depressed and 
drinking more.  She reports no social support in the area and 
this it difficult for her, though she denies any SI or 
neurovegetative symptoms.  The patient is currently receiving 
radiation therapy s/p breast surgery. She saw Dr. ___ 
___, at which time she agreed to come in to the hospital 
for alcohol detox.  This was discussed with Dr. ___ on Deac 
4 and a bed was placed on hold. She has been drinking >1 liter 
of red wine daily for the past several months and her last drink 
was right before coming to the ED.  She denies any history of 
delirium tremens or seizures. She does report a history of 
blackouts in the past.  She identifies her relapse into drinking 
after her mother, a ___, passed away last year. She has 
had periods of sobriety in the past and has had multiple 
previous hospitalizations for alcohol detox, most recent . She 
currently complains of sweats and shakiness, denies nausea and 
vomiting.  Initial CIWA score = 23. She denies any SI/SA, HI/HA, 
hallucinations/delusions.

 
Past Medical History:
PPH: 
Outpatient psychiatrist, Dr. ___,
being treated for alcohol dependence and mood disorder with
Effexor XR, Abilify, and Trazodone.

PMH:
-hepatitis C
-cirrhosis due to alcohol abuse and hepatitis C
-recently diagnosed breast cancer s/p lumpectomy ___, currently 
undergooing XRT 
-asthma
 
Social History:
___
Family History:
-Mother reported +CAD with first event at age ___, second event 
in ___.  Also with h/o DM.
-Father with CAD - at age ___

Family psychiatric history: no history of suicide, substance 
abuse, or major mental illness.

 
Physical Exam:
Medically stable and safe for admission. Normal physical exam. 

VS: BP:156/99 HR:110 temp: resp:16 O2 sat:98

MSE:
Appearance:dressed in hospital gown, hair pulled neatly back, no 
make up, good eye contact
Mood and Affect:"alright", somewhat flattened but appropriate to 
content, smiles occasionally
Behavior: slight tremulousness in both upper extremities
Cognition:
   Attention:serial sevens, stopped at 93, "I'm not good at 
mathematics" MOYF correct and rapid, MOYR slow/stopped at 
___
   Memory:long term memory intact, ___ registration, ___ recall
   Fund of knowledge:average
   Calculations: "3x7=21", "9x4=16"
   Abstraction:Apple, Orange ="similar in weight", Grass is 
always greener="grass is different on other side"
   Speech: normal volume and tone, "I have to stop drinking, 
it's too much"
   Language: accented ___, no neologisms
Thought process/associations: Somewhat tangential, no LOA, no 
FOI
Thought Content:
   Hallucinations: no hallucinations in any modality
   Delusions: none
   Homicidal ideation: none
   Suicidal ideation: none
Judgment: impaired
Insight: fair

 
Pertinent Results:
___:
WBC-4.5 RBC-4.03* HGB-13.9 HCT-40.4 MCV-100* MCH-34.6* MCHC-34.4 
RDW-15.2
NEUTS-64.2 ___ MONOS-4.7 EOS-0.9 BASOS-0.7   PLT 142
GLUCOSE-94 UREA N-10 CREAT-0.7 SODIUM-138 POTASSIUM-3.6 
CHLORIDE-105 TOTAL CO2-23 ANION GAP-14
ALT(SGPT)-55* AST(SGOT)-152* ALK PHOS-99 TOT BILI-0.7 LIPASE-69*
CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.1   TSH-2.1    HCG-<5
SERUM TOX:  ASA-NEG ETHANOL-76* ACETMNPHN-NEG bnzodzpn-NEG 
barbitrt-NEG tricyclic-NEG

U/A:  COLOR-Yellow APPEAR-Clear SP ___  BLOOD-NEG 
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG 
UROBILNGN-NEG PH-5.0 LEUK-NEG
URINE TOX:  bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG 
amphetmn-NEG mthdone-NEG
 
Brief Hospital Course:
1. LEGAL: ___
2. PSYCHIATRIC:
On admission the patient's home psychiatric meds were continued 
which included: Effexor XR, Abilify, Remeron and Trazodone PRN 
for insomnia.  The patient was under good behavioral control on 
the unit, with no safety concerns.  Her mood improved throughout 
hospitalization as her detox progressed and discharge plans were 
set in place.

3. MEDICAL
-Etoh detox: the patient presented in moderate alcohol 
withdrawal and was placed on a standing Ativan 1mg PO Q6H dose 
with PRN doses given for CIWA >7 every two hours. This was 
tapered over the course of her hospitalization so she could be 
discharged without Ativan.
-Breat CA: the patient was transported for two radiation 
treatments on ___ during her hospitalization. She 
will continue the treatments as an outpatient on discharge. 

4. PSYCHOSOCIAL
-The patient currently has outpatient behavioral health 
treaters, psychiatrist Dr. ___ therapist ___ whom 
she will follow-up with after discharge. She also will continue 
to participate in Ms ___ substance tx group. The patient will 
also be referred to dual diagnosis evening treatment program at 
___ in ___ upon discharge.

5. DISPO
-The patient is being discharged back to home. Her daughter will 
provide transportation to and from appointments.  She will be 
going to ___ IOP in ___ starting on the day of 
discharge.
 
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - 2 puffs INH Q4-6H as needed for 
shortness of breath, wheeze
ARIPIPRAZOLE [ABILIFY] - 10 mg Tablet - 1 Tablet(s) by mouth at 
bedtime
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs 
INH twice a day
MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth before sleep
OMEPRAZOLE -  (Prescribed by Other Provider) - 20 mg Capsule, 
Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day
TRAZODONE - 50 mg Tablet - ___ to 1 Tablet(s) by mouth at 
bedtime as needed for insomnia
VENLAFAXINE [EFFEXOR XR] - 75 mg Capsule, Sust. Release 24 hr - 
3 Capsule(s) by mouth every morning
 
Discharge Medications:
1. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO QHS (once a 
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at 
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
3. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3) 
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*90 Capsule, Sust. Release 24 hr(s)* Refills:*0*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff 
Inhalation BID (2 times a day).
Disp:*1 inhaler* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve 
(12) hours as needed for left breast pain.
Disp:*14 Tablet(s)* Refills:*0*
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for 
Nebulization Sig: ___ puffs Inhalation Q6H (every 6 hours) as 
needed for wheeze, sob.  
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as 
needed for insomnia.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Axis I: Major depressive disorder, partially treated; r/o 
substance induced mood disorder; etoh dependence; PTSD
Axis II: deferred
Axis III: breast cancer, chronic hepatitis C, liver cirrhosis, 
asthma
Axis IV: unemployed, health issues, life altering event, limited 
social supports
Axis V: 55

 
Discharge Condition:
Medically stable and safe for discharge.
MSE: Well-groomed ___ F dressed in street clothes.  No 
abnormal behaviors. Speech normal in rate, volume, prosody. 
Affect is brighter, full range. Thought process linear. Thought 
content future oriented, no delusions/paranoia/AVH/SI.  
Insight/judgment is fair.
 
Discharge Instructions:
-Please take medications as prescribed.
-Please follow up with outpatient appointments as scheduled.
-Please call ___ or return to your nearest ER if having thoughts 
of hurting yourself or others.
 
Followup Instructions:
___

{'sweats': ['Other and unspecified alcohol dependence', 'continuous'], 'shakiness': ['Other and unspecified alcohol dependence', 'continuous'], 'blackouts': ['Other and unspecified alcohol dependence', 'continuous'], 'depressed': ['Major depressive affective disorder', 'recurrent episode', 'unspecified'], 'drinking more': ['Other and unspecified alcohol dependence', 'continuous'], 'no social support': ['Posttraumatic stress disorder'], 'radiation therapy': ['Malignant neoplasm of other specified sites of female breast'], 'hepatitis C': ['Chronic hepatitis C without mention of hepatic coma'], 'cirrhosis': ['Alcoholic cirrhosis of liver'], 'asthma': ['Asthma', 'unspecified type', 'unspecified']}