SUD follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a ‍substance use disorder follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimproveddeterioratedvariableresolved



Current substance use: ‍ ‍none, ‍alcohol, ‍opioids, ‍cannabis, ‍stimulants, ‍hallucinogens, ‍inhalants, ‍sedatives

Frequency of use: ‍ ‍times per day

Last use: ‍ ‍days ago

Cravings: ‍nonemildmoderatesevere

Withdrawal symptoms: ‍nonemildmoderatesevere



Current symptoms:

‍mood swings

‍anxiety

‍depression

‍insomnia

‍restlessness

‍irritability

‍fatigue

‍poor concentration

‍decreased performance at work/school

‍social withdrawal

‍legal issues

‍financial issues



Contributing factors:

no history of: ‍anxiety disorders, ‍depression, ‍bipolar disorder, ‍schizophrenia, ‍PTSD, ‍ADHD, ‍chronic pain

no use of: ‍medications related to the listed conditions



Psychotherapy: ‍completedongoingabandonednot interested ‍, ‍effectiveineffective,

Other interventions tried: ‍ ‍none, ‍supportive relationships, ‍coping strategies, ‍12-step programs, ‍mindfulness-based stress reduction, ‍effectiveineffective



Labs: LFTs: ‍ ‍normal, Urine drug screen: ‍positive for negative



Social support: ‍goodaveragepoornone

Employment status: ‍employedunemployedretiredstudent

Living situation: ‍stableunstablehomeless

Legal issues: ‍nonependingprobationincarceration

Financial issues: ‍nonesomesevere





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal, cornea ‍intact, ‍PERRL, extraocular movements ‍intact, OD 20/‍, OS 20/‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Substance use disorder ‍likelysuspectedpossible, ‍well-controlled

DDx: substance use disorder, substance-induced mood disorder, substance-induced psychotic disorder, substance-induced anxiety disorder, substance-induced sleep disorder, substance-induced sexual dysfunction, substance-induced neurocognitive disorder, withdrawal syndrome, depression, anxiety, bipolar disorder, personality disorders, ADHD, behavioral addiction, toxicity/poisoning, delirium, malingering





PLAN:

Investigations:

- Urine drug screen

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍LFTs, ‍hepatitis B, ‍hepatitis C, ‍HIV

- ECG if on QT prolonging medications

Treatments:

- Psychoeducation about substance use disorder

- Encourage abstinence from substance use

- ‍Medications for opioid use disorder

- ‍Medications for alcohol use disorder

- ‍Medications for nicotine use disorder

- ‍Antidepressants

- ‍Antipsychotics

- ‍Anxiolytics

- ‍Sleep aids

- ‍Thiamine

- ‍Multivitamin

Further care:

- Referral to addiction medicine clinic

- Referral to addiction services

- Referral to social worker

- Referral to psychologist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop

- Referral to ER if severe withdrawal symptoms, suicidal ideation, or psychosis