Reference no: EM133087969

Question : Respond to the given diagnosis and treatment plan. Agree/disagree? Why?

Chief Complaint: "I'm feeling ok today, a little tired" SUBJECTIVE: HPI: Patient is interviewed in person with attending psychiatric provider in attendance for duration of exam. L.N. is a 63yo female with alcohol use disorder admitted for suicidal ideation and worsening depression in the setting of medication non-compliance. In the emergency room her BAC was 153 at arrival.

She presented to the ER for suicidal ideation after being brought in by ambulance from home. She admits to increased alcohol consumption for the past few weeks due to medication non-adherence. Patient states that she had not been able to connect with her outpatient provider to obtain her medications. She reports that when she doesn't take her medication, she is unable to sleep. She states that when her sleep is affected, it causes her OCD to worsen in turn causing her to consume alcohol to try to sleep and alleviate her symptoms. Patient states she was drinking "3-4 glasses" of wine per day. She doesn't have any particular concerns with her alcohol intake and states that if she is able to sleep well, she will not drink alcohol.

She is not interested in medications to help with alcohol at this time, she states she has "tried them all and none of them work". She is, however, interested in seeking placement "in a halfway house, so I can get some extra help when I leave here." Last alcohol intake was 6 days ago. She has been unscored on CIWA since transfer from the ER and it was discontinued 24 hours ago. L.N. reports that her sleep last night was approximately 5 hours in duration. She was up late reading a novel and states that reading helps her relax for sleep. She reports that it took her "an hour ot two" to fall asleep. She reports that she woke up early and then went back to sleep for several hours and reports feeling rested. L.N. continues to have pain in relation to her right hip which showed a right hip fracture at the site of her hip replacement on Xray in the ER. The ER recommended that she follow up with orthopedics (after stabilization here) for workup and treatment plan. Patient states she has "been dealing with this for 2 years, and it's not getting in better."

When asked what patient does for pain at home, she endorses first that she takes 800mg of ibuprofen every 4 hours at home, but then she corrects herself to say she takes 800mg of ibuprofen three times per day and later states she takes 1600mg per day. She reports that tylenol is ineffective for her chronic pain from osteoporosis, but is occasionally effective for her headaches. Since she has been inpatient, L.N. has been attending some groups and has been reading novels which she finds "helps some". She is requesting an increase to her Prozac (restarted at 40mg at admission two days ago) and increase to Trazodone to help with sleep, she is currently prescribed 100mg at bedtime, with a one time additional 50mg prn dose. She would like to resume her previous dose of Prozac 80mg and was given 40mg yesterday and today with a plan to titrate upwards. L.N. has a medical history reported as osteoporosis, GERD, thoracic scoliosis with chronic pain and s/p right total hip replacement in August 2019. She does not take any prescription medications besides her psychiatric meds. OBJECTIVE: Vital Signs: BP 124/81, HR 94, Temp 97.0, Resp 20, O2 Sat 97%, Pain 6/10.

MENTAL STATUS EXAM: APPEARANCE: Appears older than stated age. Attired in hospital sweatsuit which is clean and non- wrinkled. Hair appears unkempt/unclean. Engaged in interview. Makes appropriate eye contact. SPEECH: Speech is coherent, normal rate, normal volume and tone. INSIGHT & JUDGMENT: Insight and judgement moderately impaired. ORIENTATION: Oriented to person, place, time, and situation.

THOUGHT PROCESS: Thought process is linear and coherent.

THOUGHT ASSOCIATIONS: Loosening of associations are not present.

ATTENTION/CONCENTRATION: Attention is grossly intact, patient tracks well. LANGUAGE: Verbal fluency and auditory comprehension are intact. Patient is hard of hearing.

MOOD AND AFFECT: Depressed. Affect is flat.

THOUGHT CONTENT: Thought content is without auditory or visual hallucinations or paranoia. Denies violent, suicidal or homicidal ideation currently but recent SI. GAIT and STATION: patient with irregular gait/limp using modified wheeled walker.

ASSESSMENT: F33.2 Major Depressive Disorder, Recurrent Patient meets DSM V criteria for MDD and has a PHQ9 score at admission of 21 with suicidal ideation. Patient's current PHQ score is 16 and denies current suicidal ideation.

A recent study by Sun et al., indicates that the PHQ9 continues to be a reliable indicator for patients with MDD in the inpatient setting and should continue to be used as a rapid and concise measurement of depression (Sun et al., 2020). DDX: Bipolar Disorder: patient denies ever having manic or hypomanic symptoms F10.20 Alcohol Use Disorder, Severe Patient with longstanding alcohol use and no current concrete plan to discontinue use. She would be interested in a halfway house, however at her last discharge she was noted to purchase and consume alcohol while she was in the community during the daytime hours. According to an article by Carton et al, those who consume alcohol (who also carry a diagnosis of MDD) displayed a more severe profile than those without alcohol use (Carton et al., 2018). F42.9 Obsessive-Compulsive Disorder: patient with longstanding diagnosis of OCD. Patient meets criteria of OCD in the DSM-V with recurrent, persistent thoughts and impulses that are not considered every day worries and she was able to demonstrate that she met the criteria for compulsive behavior. L.N. has been consistently treated with SSRI and self-reports that her symptoms are well controlled with Prozac and she rapidly decompensates when not taking her SSRI. An article by Szechtman et al., advocates expanding treatment options which includes the need to expand current pharmacologic treatments as a significant portion of patients with diagnosis of OCD do not achieve relief of symptoms with currently available modalities (Szechtman et al., 2019). M81.0 Osteoporosis M25.551 Right Hip Pain M41.

9 Scoliosis Current medications:

a. Prozac 40mg PO Daily

b. Prazosin 0.1mg PO Daily at HS

c. Trazodone 100mg at HS with 50mg x 1 dose prn at HS

d. Ibuprofen 400mg Q12hours prn PLAN:

Will titrate Prozac to 60mg today by giving one 20mg dose now. Remain at 60mg tomorrow with titration to 80mg through the weekend. We will increase trazodone to 200mg at bedtime. Will start patient on Celebrex 100mg BID for chronic pain. Have also discussed the side effects of chronic ibuprofen use (in addition to her alcohol consumption) and patient consents to addition of Celebrex with tylenol only as needed for breakthrough pain. PMHNP and social work to meet with patient daily. Will continue to search for placement and will obtain follow-up appointments for PCP, outpatient mental health prescriber and therapist and orthopedics.

APA FORMAT 200 WORDS 2-3 REFERENCES INCLUDES DSM-5 RECOMMENDATION Patient: