Collin Grimes Patient Write Up September 13th
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Collin Grimes – Patient Write Up – September 13, 2015 History: Chief Complaint/HPI A 26 year old man was seen with a chief complaint of “oxy addiction” and states that he desires to “get clean”. Patient reports a 3 year history of opioid dependence starting after a knee surgery while in the military. Patient reports taking 5-10 30mg Oxycodone intravenously every day. Patient states last time of use was 2 days ago and is interested in an ILP (Independent Living Program) offered by the VA. Patient states his son as a significant motivator in stopping his opioid use. Past Medical History/Surgical History Patient has a medical history of anxiety and depression; has been prescribed benzodiazepines and SSRIs in the past. Patient has surgical history of right knee surgery. Social History/Family History Patient reports use of between 150 and 300 mg of oxycodone intravenously per day. Patient reports occasional use of morphine 60mg PO “when he could find it”. Patient denies tobacco use. Patient lives at home in Roland, OK with his son. Patient denies any significant family medical history. Current Medications Zoloft Lorazepam Allergies: No Known Drug Allergies Review of Systems: Constitutional - Patient denied fever, fatigue - Patient denied headaches - Patient reports diaphoresis at times during opioid withdrawals Eyes
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Transcript of Collin Grimes Patient Write Up September 13th
Collin Grimes – Patient Write Up – September 13, 2015
History:Chief Complaint/HPI
A 26 year old man was seen with a chief complaint of “oxy addiction” and states that he desires to “get clean”. Patient reports a 3 year history of opioid dependence starting after a knee surgery while in the military. Patient reports taking 5-10 30mg Oxycodone intravenously every day. Patient states last time of use was 2 days ago and is interested in an ILP (Independent Living Program) offered by the VA. Patient states his son as a significant motivator in stopping his opioid use.
Past Medical History/Surgical HistoryPatient has a medical history of anxiety and depression; has been prescribed
benzodiazepines and SSRIs in the past. Patient has surgical history of right knee surgery.
Social History/Family HistoryPatient reports use of between 150 and 300 mg of oxycodone intravenously per day. Patient reports occasional use of morphine 60mg PO “when he could find it”. Patient denies tobacco use. Patient lives at home in Roland, OK with his son. Patient denies any significant family medical history.
Current MedicationsZoloftLorazepam
Allergies:No Known Drug Allergies
Review of Systems:Constitutional
- Patient denied fever, fatigue- Patient denied headaches- Patient reports diaphoresis at times during opioid withdrawals
Eyes- Patient reports eye redness and trouble sleeping- Patient does not use glasses or contacts - Patient denied purulent discharge
ENT- Patient denied epistaxis or sore throat- Patient denied ear fullness or pain- Patient denied sinus pressure or sinus drainage
Cardiovascular- Patient denied chest pain, or syncope- Patient denied palpitations. No edema.
GI
- Patient reported reduced appetite and nausea without vomiting- Patient reported minimal diarrhea x2 days- Patient denied abdominal tenderness
GU- Patient denied painful urination- Patient denied hematuria
Musculoskeletal- Patient denied back or neck pain- Patient denied arthralgias
Skin- Patient denied cellulitis, rash
Neurologic- Patient reported excessive yawning
Psychiatric- Patient reported severe anxiety exacerbation after cessation of opioids. - Patient reported minimal depression. States his medication reduces his depression
significantly. - Patient denies homicidal or suicidal ideations.
Physical Exam
Constitutional- Vital Signs:
o Pulse: 96o Resp: 18o Temp 98.8 (Tympanic)o O2 Sat: 99% on RAo Blood Pressure: 154/94
- Pain: 0 (1-10 Scale)Head
- Head exam included findings of head atraumatic, normocephalicEyes
- Eyelids normal to inspection, pupils equally round and reactive to light, extraocular muscles intact, conjunctiva and sclera mildly injected.
ENT- Nose exam normal, pharynx exam normal
Neck- Neck exam included findings of normal range of motion, trachea midline
Lymph- No lymphadenopathy, enlargement, or masses
Respiratory Chest- Respiratory exam included findings of normal breath sounds; breath sounds clear,
patient moderately dyspneic.Cardiovascular
- Heart Rate Tachycardic; Heart sounds normal; No bruits or rubs on auscultation of heart or carotid arteries
Abdomen- Abdominal exam included findings of soft with no scarring noted. No striations.- No tenderness noted upon palpation- Liver and Spleen within normal limits- No pulsatile masses or abdominal bruits- Hyperactive bowel sounds noted
Upper Extremity- Upper extremity exam included findings of inspection normal; range of motion
normal- Lower extremity exam included findings of inspection normal; range of motion
normal
Genitalia- Genital Exam Deferred
Neuro- Neuro exam findings include patient oriented to person, place, and time; speech
normalSkin
- Skin exam included findings of skin warm, moist, and normal in color- No jaundice of the skin noted
Psychiatric- Psychiatric exam included findings of patient oriented to person, place, and time;
restricted affect; mood “ready to move on and a little nervous”
Lab FindingsUrine Drug Screen Positive for Benzodiazepines and Opioids
Assessment:1) Opioid Dependence
Plan:1) Continue Lorazepam for anxiety2) Continue Zoloft for depression3) Follow up with the ILP provided by the VA
Follow up1) Patient referred to the VA’s ILP and counseled on opioid addiction and withdrawal.
Literature Search:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/
http://emedicine.medscape.com/article/287790-treatment
