UT Health San Antonio (Acct #3131)

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