Major depressive affective disorder recurrent episode severe without mention of psychotic behavior Suicidal ideation Opioid type dependence continuous Acute alcoholic intoxication in alcoholism continuous Other chronic pain Pain in joint shoulder region
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: PSYCHIATRY
 
Allergies: 
Hayfever / Adhesive Tape / Latex
 
Attending: ___.
 
Chief Complaint:
"As ___ would say, the black dog is upon me. I've 
had an inordinate amount of unpleasantness."
 
Major Surgical or Invasive Procedure:
None.
 
History of Present Illness:
___ yo married white man c a h/o accident ___ years ago resulting 
in nerve damage to right arm and associated chronic pain on 
opiates c/b alcohol abuse/dependence and depression who was 
brought to ___ ED by his wife at the insistence of Dr. ___ 
___ for psychiatric evaluation.  On ___ Mr. ___ 
impulsively ingested 20 to 23 pills of duloxetine 30 mg (he and 
his wife were not sure how many pills were left in the 
bottle--wife said she thought none and husband said around 30 
were left).  Patient took this ingestion while alone, but could 
not clarify whether he was intoxicated or not. Patient could not 
really give specifics re his thought process around taking the 
pills, but minimized the ingestion as not being suicidal in 
nature.  Patient stated that he thought, ___ I'd go to sleep, 
that's all, a relaxing 4 hour nap."  Patient
reported that he has chronic sleep problems.  He says that 
normally he has a good appetite, but he has not been eating 
since the overdose.  He reported that his concentration and 
ability to enjoy things (e.g., his music collection, which he 
tells me is one of the largest in the country at 33,000 records) 
has not diminished, even in the context of his sense of being 
depressed. 

Despite his chief complaint re an "inordinate amount of 
unpleasantness," patient identified the main stressor as 
witnessing his mother's decline as she suffers from a 
progressive dementia.  She is living in ___, though they 
talk on the phone regularly.  He reported that he stopped 
working a few months ago, although he still strongly identifies 
c his profession as working ___.  He said that this was a 
voluntary decision to stop working, although he acknowledged 
that the pain and limits in his functioning after the accident 
did have an impact on his worklife.  

Patient denied any h/o manic or psychotic episodes.  Even though 
patient's alcohol level this morning before 11 am was nearly 
200, patient denied having anything to drink this morning.  
Patient reported that he had 5 large glasses of straight vodka 
last night when pressed for an explanation as to how his alcohol 
level might be so high.  
 
Past Medical History:
- h/o surgery for perforated duodenal ulcer (req 21 units of
blood) at ___.
- Steatosis with inflammation and stage III portal fibrosis.
- Multiple orthopedic injuries: h/o bilateral knee surgeries, 
h/o left labrum shoulder repair, h/o a fall/slip on ice in ___ 
when he injured his right shoulder and right humerus shaft. 
- Ruptured appendix and subsequent perotinitis

Past Psychiatric History: Patient has no previous h/o inpatient 
psychiatric hospitalizations or suicide attempts.  Saw a 
psychiatrist as a teen for high school related angst.  Took an 
antidepressant, possibly amitriptyline, many years ago, but had 
sexual side effects.  More recently has been taking duloxetine 
for pain and depression prescribed by Dr. ___.
 
Social History:
From ___ area originally, older of two sons born to married 
parents.  Reported that he was an excellent student, went on to 
college, first at ___, then transferred to ___ before 
ultimately graduating from ___ c a degree in ___. Worked 
initially for ___ then went on to work in ___ at ___ 
(___ at ___) for his professional career until 
retirement a few months ago.  Patient lives c his wife of ___ 
years, no children, has cats.  Not particularly religious. 
Denied weapons in the home.

Substance Abuse History:
In the ED, patient minimized his alcohol consumption, denied 
daily drinking, denied drinking to blackout, denied drinking & 
driving. On the inpatient unit, he reported drinking daily, 
sometimes vodka straight from the bottle. Admitted to drinking 
up to 5 large glasses of straight vodka the night prior to 
admission.  Wife reported that she was not aware of the extent 
of his alcohol use, but she does know that he drinks alcohol.  
No h/o withdrawal seizures.  Denied any other h/o drug use.  
Smokes ___ cigarettes a day.
 
Family History:
Per patient, his brother has a history of some kind of chronic 
psychotic illness (possibly schizophrenia) and is 
institutionalized (brother killed the family dog when brother 
was ___, which seems to have been the onset of his symptoms). 
Father died in ___ from complications of CHF, but he was 
also a heavy drinker.  Mother is ___, lives in ___ and ___ 
Alzheimer's dementia.
 
Physical Exam:
ED Exam: 98.0, 94, 157/94, 16, 98% RA.  Pain (RUE) ___.  White 
male, sitting up in bed, wearing a t-shirt and a hospital 
___. + palmar erythema. Mild diaphoresis by the time I met c 
patient at 1:15 pm (would have still had alcohol in his system). 
 + jaw twitching.  + tremors.  Speech tremulous, normal use of 
language, expansive vocabulary.  Mood is "better" c a slightly 
irritable
affect at times.  Thoughts organized, denied paranoia, denied 
abnormal perceptions.  Minimized recent ingestion, despite 
potential lethality of ingestion.  Denied suicidal intent c 
ingestion.  Denied thoughts of harming others.  Insight into 
problems c alcohol is quite limited, prominent denial. Judgment 
limited. 

Oriented in full detail.  MOYF/B intact.  Calculations intact. 
STM ___ reg, ___ recalled, ___ c category clue.  Repetition
intact.  Presidents to ___.  Proverbs appropriately 
abstract.

HEENT: Normocephalic. PERRL, EOMI. ___ normal. Oropharynx clear.
Neck: Supple, trachea midline. No adenopathy or thyromegaly.
Back: No significant deformity, no focal tenderness
Lungs: Clear to auscultation; no crackles or wheezes.
CV: Regular rate and rhythm; no murmurs/rubs/gallops; 2+ pedal 
pulses
Abdomen: Soft, nontender, nondistended; no masses or 
organomegaly.
Extremities: Severe psoriasis on lower extremities, worse on 
left. No clubbing, cyanosis, or edema.
Skin: Warm and dry. 
Neurological:
  *Cranial Nerves-
       I: Not tested
       II: Pupils equally round and reactive to light 
bilaterally. Visual fields are full to confrontation.
      III, IV, VI: Extraocular movements intact bilaterally 
without nystagmus.
      V, VII: Facial strength and sensation intact and 
symmetric.
      VIII: Hearing intact to voice.
      IX, X: Palatal elevation symmetrical.
      XI: Sternocleidomastoid and trapezius normal bilaterally.
      XII: Tongue midline without fasciculations.
   *Motor- Normal bulk and tone bilaterally. No abnormal 
movements, tremors. Strength full power ___ throughout except 
for all muscles on right arm which are ___. Patient's effort 
questionable on this part of the exam and reported pain on 
testing. No pronator drift.
   *Sensation- Intact globally
   *Reflexes- B T Pa
   *Coordination- Normal on finger-nose-finger, rapid 
alternating movements
 
Pertinent Results:
    WBC    RBC    Hgb    Hct    MCV    MCH    MCHC    RDW   Plts
    7.8   4.67   16.7   48.9    105*  35.8*   34.2   14.8   163 

    Glucose   BUN    Creat     Na    K    Cl    HCO3   AnGap 
      89       19      0.8    141   4.2   96     25     24* 

    Serum tox screen alcohol 185 at 10:53 am on ___, o/w neg

    Urine tox screen neg
 
    U/A  SG 1.020, blood large, protein 75, ketones 50, WBC ___, 

    bact few.

 
Brief Hospital Course:
Psychiatric: 
Since admission, Mr. ___ has actively engaged in medical 
treatment for the alcohol dependence and depression. He 
reflected on events leading to hospital admission, family/life 
stressors, alcohol dependence, and suicidal ideation. His wife 
visited every day and was an active part of his treatment and 
disposition planning. Mr. ___ initially required high doses 
of ativan for signs and symptoms of EtOH withdrawal, but he was 
eventually tapered off benzodiazepines uneventfully. During his 
hospital course, he was started on Celexa to address his 
depression. However, since he continued to have problems with 
sleep, he was changed from Celexa to Seroquel 50mg QHS. At time 
of discharge, pt states that he has many things to live for, 
including his main support, which is his wife. He is looking 
forward to spending time with his wife, his cats, and his 
friends, and he is hoping to spend some time "in the great 
outdoors" this weekend. He is currently denying any suicidal 
ideation and he feels that his overdose was an impulsive act 
that he will not repeat. He expressed ambivalence regarding 
following up at ___ for his alcohol dependence. However, he 
expressed a desire to stay sober and is willing to meet with an 
outpatient psychiatrist and therapist for support and continuity 
of care.  

Safety: He was maintained on 15 minute checks and had no 
behavioral triggers while on the unit. 

Groups/Milieu: He attended the Coping Skills group while an 
inpatient.

Legal: ___
Medications on Admission:
- Duloxetine 30 mg po daily
- Oxycodone 15 mg po q 4 hours ATC 
- Pantoprazole 40 mg po bid
- Gabapentin 300 mg po tid
 
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4H (every 4 
hours) as needed for pain for 1 weeks.
Disp:*126 Tablet(s)* Refills:*0*
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 
times a day) for 1 weeks.
Disp:*21 Capsule(s)* Refills:*0*
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS.
Disp:*30 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Major Depressive Episode, recurrent 
Alcohol Dependence

 
Discharge Condition:
MSE: pleasant, talkative
Speech: goal directed
Mood/Affect: 'better'/brighter
T. Form: no LoA/TT/TB
T. Content: no delusions/hallucinations/paranoid ideation
Denies SI/HI
Cognition: a and o x 3
Judgment/Insight: fair

 
Discharge Instructions:
You will be discharged home and follow up with your outpatient 
primary care doctor, ___ your outpatient psychiatrist. 
You will also be discharged with a prescription for Celexa. 
 
Followup Instructions:
___

{'inordinate amount of unpleasantness': ['Major depressive affective disorder', 'recurrent episode', 'severe', 'without mention of psychotic behavior'], 'impulsively ingested': ['Suicidal ideation'], 'chronic pain': ['Other chronic pain'], 'pain in joint': ['Pain in joint', 'shoulder region'], 'alcohol level': ['Acute alcoholic intoxication in alcoholism', 'continuous'], 'alcohol consumption': ['Opioid type dependence', 'continuous']}