0 Bewertungen0% fanden dieses Dokument nützlich (0 Abstimmungen)
58 Ansichten2 Seiten
This case summary involves a 31 year old white male seen for an initial visit at a VA hospital presenting with chief complaint of "I didn't mean it." He has a history of alcohol use and was admitted for detox and suicidal ideation. The student spent 25 minutes with the patient and 10 minutes consulting with their preceptor. Diagnoses included alcohol dependence in remission. Recommendations included discontinuing 1:1 observation for safety as the patient was no longer suicidal, continuing detox protocol, and referring the patient to outpatient substance abuse and mental health treatment with no new medications.
This case summary involves a 31 year old white male seen for an initial visit at a VA hospital presenting with chief complaint of "I didn't mean it." He has a history of alcohol use and was admitted for detox and suicidal ideation. The student spent 25 minutes with the patient and 10 minutes consulting with their preceptor. Diagnoses included alcohol dependence in remission. Recommendations included discontinuing 1:1 observation for safety as the patient was no longer suicidal, continuing detox protocol, and referring the patient to outpatient substance abuse and mental health treatment with no new medications.
This case summary involves a 31 year old white male seen for an initial visit at a VA hospital presenting with chief complaint of "I didn't mean it." He has a history of alcohol use and was admitted for detox and suicidal ideation. The student spent 25 minutes with the patient and 10 minutes consulting with their preceptor. Diagnoses included alcohol dependence in remission. Recommendations included discontinuing 1:1 observation for safety as the patient was no longer suicidal, continuing detox protocol, and referring the patient to outpatient substance abuse and mental health treatment with no new medications.
Case ID #: 1444-20180412-002 (Status: Approved) Date of Service: 4/12/2018
Student Information - Krug, Janice Semester: Spring Course: NURS 6623: PMHNP Dx & Mgmt I: Clin App Preceptor: Carroll, David Clinical Site: South Texas Veterans HCS - VA Hospital Setting Type: Patient Demographics Age: 31 years Race: White, Non Hispanic Gender: Male Insurance: No insurance Referral: Physician Clinical Information Time with Patient: 25 minutes Consult with Preceptor: 10 minutes Type of Decision-Making: Moderate complexity Student Participation: Primary (>50%) Reason for Visit: Initial Visit Chief Complaint: "I didnt mean it." Encounter #: 1 Type of HP: Expanded Problem Focused Social Problems Addressed: Interpersonal Relationships Substance Abuse
ICD-10 Diagnosis Codes
#1 - F10.21 - ALCOHOL DEPENDENCE, IN REMISSION CPT Billing Codes #1 - 99254 - INPATIENT CONSULT, 3 KEY COMPONENTS:COMPREHENSIVE HX;COMPREHENSIVE EXAM; MED DECISION MOD COMPLEX Birth & Delivery Medications # OTC Drugs taken regularly: 0 # Prescriptions currently prescribed: 6 # New/Refilled Prescriptions This Visit: 0 Types of New/Refilled Prescriptions This Visit: Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes 31 yo male with chrinic hx of etoh use admitted for etoh detox and si. psychiatry consulted for si.
+ word recall defecit 1/4
+murmur +dysmetria L>R + mood "depressed and irritable" +interpersonal realtionship problems with girlfriend states "I need to get away from her, she, she stresses me out" +si when intoxicated "I thought about a knife and a bathtub" -si currently +contracts for safety -denies hx of mental health problems -not on any antidepressants
recommendations -dc 1:1 for safety as pt is no longer suicidal -continue with ciwa protocol -outpatient substance use and mental health treatment referral -no new meds at this time