Reference no: EM133732866
Assessment:
Adjustment disorder with mixed emotional features, Methamphetamine dependence Disorder, Uncomplicated, Cannabis dependence Disorder, continuous, Hallucinogen dependence, in remission, Cocaine dependence, in remission, and Asthma.
Current Medications:
a. Sertraline 50mg oral once daily for the treatment of depression and anxiety.
c. Hydroxyzine pamoate 50mg oral as needed every 8 hours for anxiety.
c. Albuterol 90mcg take 2 puffs every 4 hours as needed for the symptom of shortness of breath.
d. Thiamine Hydrochloride, 100mg oral per day for supplement (also known as Vitamin B1).
Plan:
The patient will undergo a 90-day course of individual and group treatment at BHRF to prevent a recurrence of substance abuse. The patient will also ensure that they attend all scheduled appointments with their primary care physician. Ensure that you adhere to the suggested drug regimen and schedule a follow-up appointment in 4 weeks to assess the dosage and efficacy of the newly prescribed meds. Ongoing patient education regarding the need of adhering to treatment and therapeutic regimen, as well as the advantages of psychotherapy and community services. The patient is routinely informed about the advantages of practicing good sleep hygiene and encouraged to engage in group activities and participate in the therapeutic environment.
She is instructed to maintain a healthy weight, engage in regular physical activity, consume a nutritious diet, abstain from alcohol, and refrain from smoking. The patient's drug regimen was modified, with certain dosages being escalated and other prescriptions, such as Ambien, being stopped. The dosage of Setraline was increased from 25mg to 50mg per day, while the dosage of hydroxyzine was also increased from 25mg to 50mg. The laboratory tests that were requested include a complete blood count (CBC), comprehensive metabolic panel (CMP), lipid panel, thyroid stimulating hormone (TSH), human chorionic gonadotropin (HCG, for pregnancy), hemoglobin A1c (to screen for diabetes), urinalysis, and drug