65.Wk7

Jane,

This patient needs a SOAP note completed. If there is any information you want to add, feel free. It doesn’t explain the basis of his PTSD but it was from the things he has seen while working as a police officer. Feel free to add that or don’t. I trust whatever you think is best. Thanks!!!!!

Subjective: Patient was seen today for focused session. Patient is a 56-year-old male referred for psychiatric evaluation. This is his fifth inpatient treatment and second at RCA Devon. Patient was previously seen by Dr. Altman for psychiatric evaluation on September 18, 2020. He is known to me from previous psychiatric follow ups. During his initial psychiatric evaluation he had been started on Minipress 1 milligram nightly, Zoloft 50 milligrams daily and Remeron 7.5 milligrams nightly. No changes were subsequently made after the psychiatric evaluation because patient reported that he was doing well. Patient stated that after he was discharged he did not have paper scripts and did not fill his prescriptions. Patient stated that he took what was left in the bottles and stopped when those ran out. Patient stated that he thought that one of the medications might have made him feel "funny". Patient could not recall which medication it was whether it was medical or psychiatric. Upon admission patient was restarted on Minipress 1 milligram nightly, Remeron 15 milligrams nightly and Zoloft 50 milligrams daily. He has been taking Vistaril 1-2 times per day. He denies any side effects to those medications currently. Patient reports symptoms of depression and anxiety related to marital discord related to relapse. Patient stated that he relapsed about a month ago and had been drinking several "airplane bottles" per day. Patient states that his son had found two of the bottles and has not spoken to him for about a month. Patient is unsure about the future of his marriage and is concerned if he will be able to return home. He denies any history of mania or hypomania. He denies any concerns with appetite. He reports that sleep has improved recently. He reports some improvement with trauma related symptoms with Minipress. His blood pressure is stable. He denies any history of hallucinations, delusions or paranoia. He denies any suicidal or homicidal ideations. He denies any side effects to his current medications. Patient is concerned that his wife will want him to do sober living which patient states he will do. He is a retired police officer after a 25 year career in the Atlantic City, New Jersey police department. He now works full-time in county investigations. Patient reports a history of 10 years of sobriety in the past. He has never trialed naltrexone or Vivitrol and is interested in trialing naltrexone or Vivitrol at discharge. Patient is also interested in finding an outside provider for psychiatry as well as marriage counseling if possible. He denies any other psychosocial changes since last admission. Previous medication trials included Lexapro, Wellbutrin, clonidine as well as his current medications. Previous reports stated that patient had dizziness from clonidine. Patient states that he believes it was from one of his other medications and stated that clonidine was helpful. He stated that Wellbutrin and Lexapro were not helpful.

Objective: Patient is robust, very well groomed, well put together, making good eye contact, he is pleasant, cooperative and highly socially engaging, his speech is fluent and non-pressured, his thought process is logical goal-directed, he is an excellent historian. His mood seems bright, he denies feeling severely depressed, his main complaint is anxiety. Nightmares have improved. Patient denies racing thoughts, denies mood swings, he adamantly denies thoughts of harming himself or others, he does not report any psychotic symptoms at this time, he is alert and oriented x 3 with above average intelligence, good insight and judgment, excellent motivation for recovery / sobriety.

Assessment: Posttraumatic stress disorder and alcohol use disorder, severe, longstanding; unspecified anxiety; Unspecified depression

Plan: Patient is currently prescribed Zoloft, Remeron and Minipress. He had previously stopped these medications shortly after last discharge. Patient reports situational depression and high anxiety related to current situation. He was admitted on June 27th and restarted on these medications. We discussed options at length. Patient requested to increase Minipress to 2 milligrams nightly, start gabapentin 200 milligrams 3 times daily and add clonidine 0.1 milligrams up to twice per day as needed. Hold parameters were ordered with clonidine as well as instructions to not give concurrently with Norvasc or Minipress. Reviewed medication side effects, risks, benefits, alternatives, and possible interactions. He denies any side effects to his current medications. Patient agrees to meet with Psychiatry in 5-7 days or sooner if needed. In the meantime, pt. verbalized understanding with intent to comply with my instructions to report any medication side effects, worsening mood, anxiety, suicidal, homicidal, or destructive thoughts to nursing staff and/or medical staff immediately.