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
- 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: 96
o Resp: 18
o Temp 98.8 (Tympanic)
o O2 Sat: 99% on RA
o Blood Pressure: 154/94
- Pain: 0 (1-10 Scale)
Head
- Head exam included findings of head atraumatic, normocephalic
Eyes
- 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 normal
Skin
- 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 Findings
Urine Drug Screen Positive for Benzodiazepines and Opioids
Assessment:
1) Opioid Dependence
Plan:
1) Continue Lorazepam for anxiety
2) Continue Zoloft for depression
3) Follow up with the ILP provided by the VA
Follow up
1) Patient referred to the VAs 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