Patient reports smoking cigarettes daily, up to one pack.

Subjective:

CC (chief complaint): “I will be going back home on August 3rd.”

HPI: D.P. is a 73-year-old Caucasian male who was set up for follow up with Mental Health Prescribing Provider appointment as he will be discharged from a residential treatment facility back to his home on August 3rd. He has been in several different supervised settings since January of 2022, and will need medications monitored by outpatient provider at this time. Patient is on commitment and will be receiving a provisional discharge from residential treatment facility through April of 2023. This last episode of care started for patient when he was initially hospitalized on inpatient mental health unit in January of 2022 due to having suicidal ideation, being intoxicated and calling the crisis line. At that time, he was on a stay of commitment, this was revoked, and patient stayed on acute unit, until a residential psychiatric bed opened at a CBHH. From the CBHH he went to the residential chemical dependency treatment center that he is currently at, and will be discharged from on August 3rd. He has an extensive history of alcohol dependence, and PTSD stemming from combat related trauma. He also notes depressive symptoms when drinking alcohol as well as when he is withdrawing from alcohol. Current symptoms include nightmares which cause sleep difficulty, lack of motivation, lack of finding joy in activates he used to, excessive alcohol use is currently in remission.

Past Psychiatric History: Patient reports a history of numerous chemical dependency treatments throughout his life (after returning from combat). He reported upon getting out of the military, “All I wanted to do is fight.” The resources for mental health were not available at that time, but he has sought mental health services in the past several years. Several years ago he engaged in individual therapy with a psychologist for about six years, “that was helpful.” He went through inpatient MI/CD treatment in the fall of 2021 for alcohol dependence and PTSD. Upon last hospitalization, patient had a loaded gun and was thinking about shooting himself. No known medication trials in the past. Denies family history of substance use disorders or mental health symptoms.

Substance Current Use: Patient reports smoking cigarettes daily, up to one pack. He was drinking alcohol (vodka) daily prior to his admission to mental health unit, sober since January 28th, 2022. Denies any further drug use. He also reports that he drinks several cups of coffee daily.

Medical History:

• Current Medications:
  • Escitalopram 10 mg p.o. QD for depression
  • Aspirin 81 mg p.o. QD with food
  • Folic Acid 1 mg p.o. QD for vitamin supplement
  • Cholecalciferol 50mcg p.o. QD for vitamin supplement
  • Menthol/M-Salicylate 10-15% topical cream – Apply moderate amount to affected area three times daily as needed for muscle and joint pain
  • Multivitamin Cap/Tab p.o. QD for vitamin supplement
  • Tiotropium 2.5mcg/Actuat 60D Oral Inhaler – Inhale 2 inhalations by mouth once a day for breathing.
  • Thiamine 100mg tab p.o. QD for vitamin supplement
  • Metoprolol Succinate 50 mg p.o. QEVE for blood pressure
  • Famotidine 20 mg p.o. BID for stomach
  • Acetaminophen 1000 mg p.o. TID PRN for pain
  • Gabapentin 200mg p.o. BID for nerve pain
  • Gabapentin 400mg p.o. QHS for nerve pain
  • Albuterol 90mcg / Actuat 200D Oral Inhaler – Inhale 2 puffs by mouth twice a day as needed for breathing.
  • Nitroglycerin 0.4mg SL tab – Dissolve one tab under tongue as needed for chest pain, if no relief after 5 minutes call 911 and take additional dose every 5 minutes up to three doses.
  • Prazosin HCL 1 mg cap p.o. QHS for nightmares
• Allergies: No known allergies.
•  

Objective:

Diagnostic results: Labs reviewed from PCP visit May 2022. A1C – abnormal (high at 6.2). CBC – within normal limits , CMP – within normal limits (abnormal HDL (low at 32).

Negative C – SSRS

Assessment:

Mental Status Examination: D.P. is a 73-year-old Caucasian male who appears his stated age. He reports having an 11th grade education. He is alert and oriented to person, place, time and situation. Affect appears blunted with irritable mood noted. He is cooperative through our session. He is appropriately dressed and appears adequately groomed. His speech is clear and coherent, with normal volume and tone, he does stumble with words at times while talking. His thought process is logical, however; he presents limited insight into his current concerns and situation. He does not appear to be responding to any auditory or visual hallucinations. There is no evidence of delusional thinking. Concentration is intact, and memory appears to be intact.

Diagnostic Impression:

Primary Diagnosis: PTSD: This patient experienced significant traumatic events while being in the service and in Vietnam for one year. He reports recurrent and intrusive memories, recurrent and distressing dreams, psychological distress when exposed to external cues, efforts to avoid external cues, diminished interests in activities, persistent negative emotional state, irritability, self-destructive behavior, sleep disturbance, and these symptoms have caused significant distress and impairment for the patient in numerous areas of life (APA, 2013). These symptoms presented after exposure to the traumatic event, indicating this is the Veteran’s primary diagnosis.

In a study by Steenkamp, et al.(2017), “Predictors of current PTSD symptoms included African-American Race, lower education level, negative homecoming reception, lower current social support, greater past-year stress.” This Veteran meets four of these five predictors, and this study reports that PTSD symptoms and severity can persist and change up to 40 years after deployment.

Differential Diagnosis: Alcohol Use Disorder (Severe) in Early Remission: This patient has been sober since January, therefore meets the criteria of being in early remission. His alcohol use disorder could be classified as severe due to the following criteria being met when he was drinking: he drank more than intended, had persistent efforts to cut down on drinking, verbalized cravings to drink, impacted his social activities due to drinking, put himself in situations that were physically hazardous, was aware of ill effects it was having and continued to drink, and he experienced tolerance and withdrawal (APA, 2013). I placed PTSD above alcohol use, as patient did not find alcohol use as problematic until after returning from combat and suffering from PTSD.

It is known that alcohol use disorder is a common comorbidity in Veterans with PTSD (Terhaag, et al., 2019). I believe they are both illnesses that need treatment, however; the PTSD was the primary trigger for this patient’s alcohol use.

Differential Diagnosis: Alcohol – Induced Depressive Disorder w/ Onset During Intoxication. This patient’s most recent suicidal ideation occurred while under the influence of alcohol, and he has reported that his depression is exacerbated when drinking alcohol and thereafter. His symptoms continue to persist after a period of sobriety. He also reports a persistent disturbance in mood , with significant diminished interest or pleasure in all or most activities related to drinking alcohol (APA, 2013).

Reflections:

I feel this case was extremely complex, from the significant physical and mental health symptoms this patient has, to the amount of care coordination needed.

I continue to have concerns about the seriousness of his past suicidal ideation, and the fact he will be discharged to his home where he lives alone. He denies suicidal ideation at this time, however; he has been sober several months, and has been in an controlled environment. I believe that a “step down” level of care would have been beneficial prior to his discharge directly to home. Due to concerns, suicide prevention coordinators in the mental health clinic are involved with this patient’s case and will be reaching out sporadically as well. It is noted that his son has removed the firearm from his home, however; the concern of him obtaining another or utilizing different lethal means is high. This places a significant ethical dilemma as it is not what I as a mental health provider would recommend for care, but, he is being managed through a commitment through the county, and they have the overall say in what happens. Ethically, I felt I needed to voice my concerns with the current plan for this patient (as I did), and support him in the ways that I could as his prescribing mental health provider.

Case Formulation and Treatment Plan:

There are no specific age-related protocols for treating older war Veterans suffering from PTSD (Daniels, Boehnlein, & McCallion, 2015). This information was taken into consideration while discussing further treatment options with this patient and the other care team members working with him.

Patient will be educated to the benefits of medication compliance (Stahl, 2021). A consult will be placed in effort to get homecare nursing to visit his home weekly to help with medication monitoring and set up’s, ongoing education and physical and mental health symptoms monitoring. Mental health provider will also educate patient to common side effects, and encourage compliance with medications.

Will re-evaluate for side effects, toleration, and discuss further plan at next appointment with MH Provider in one month. (Specifically looking at the potential of increasing Prozosin depending on occurrence and severity of nightmares upon patient returning to his own home.)

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed including increased risk for sedation and dizziness (Stahl, 2019). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions.

Client will be referred to in home skills services, in effort to start addressing his physical and mental health symptoms, and monitor medication compliance.

Client will also be referred to start individual therapy to work on addressing past trauma.

Client will be assigned an ARMHS worker through county grant funds (due to insurance and income not meeting eligibility). This will be in effort to help gain positive and healthy coping skills and manage daily life tasks.

Client has emergency numbers:Emergency Services 911. Client was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed.

Follow up with PCP as soon as able for skin concerns under left arm.

Return to clinic: In one month. Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care

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