Question

72 Report 100 HISTORY: Mr. Meyer is a 48-year-old, divorced, white male who was admitted after he was found lying on the floor in his apartment. Evidently, he had taken a fall, and he had some bruises on his face and tongue. Later, during the hospitalization, he developed delirium tremens and required to go on the ventilator. Earlier this week, I also came to see this patient, but at that time, he was given a dose of Haldol, and he was quite drowsy and sleepy. Today, I reviewed his medical records and also met with the patient for a full evaluation. He was fairly cooperative. According to the nursing staff, the patient was just transferred to the rehab hospital, but there he became non- responsive and was transferred back yesterday. During this meeting, actually, he was pretty awake, although his concentration was still somewhat poor, but he seemed a fairly good historian. As I approached the patient, he was immediately able to recognize me, saying that I saw him many years back for “mental capacity” for Social Security benefits. At that time also, the patient had a history of auditory and visual hallucinations. The patient still talks about the same symptoms, saying he is seeing different animals from the side of his eyes and that it becomes quite scary; he will see elephants, people being hanged, and when he sees these things, he gets very nervous. He also talks about having auditory hallucinations. Again, the patient corroborated that it is nothing new and it has been going on for a number of years. He has been treated with Trazodone and then with some other medication like Mellaril, but all it did was make his mouth dry. Surprisingly, related to these psychotic symptoms, he never has had any psychiatric hospitalizations. Today, the patient also admitted that he is feeling quite depressed, and he does not feel good. He has hopelessness and worthlessness feelings, but did add that he will not hurt or kill himself. Because of pain, he complains of sleep difficulties. He does get angry and irritable because the staff tries to be smart with him; like yesterday, he was talking about not eating and still they would keep on bringing food to him. However, the patient denies if he is physically aggressive to anyone. Then I also confronted the patient about his drinking habits, but the patient said it is just a rumor, saying he is not using any alcohol or street drugs, and he has no idea who is putting it in his records. He does complain of significant anxiety symptoms also. PAST MEDICAL HISTORY: Significant for hypertension, gout, hypercalcemia, and now general debility. His previous coronary angiogram was negative. MEDICATIONS: At the time of admission, the patient was on numerous medications, but now they had been cut down significantly. PAST PSYCHIATRIC HISTORY: As above. He does have a history of psychosis, but questionable treatment. FAMILY HISTORY: The patient tells me he comes from a very large family. There were 11 kids. Some of his brothers are deceased. He could not really tell me if any other brother or sister has a diagnosis of psychosis. Both of his parents are deceased. The patient has two children; both of them are doing very well—one is a teacher and another technician in a hospital. PERSONAL AND SOCIAL HISTORY: The patient was married. His marriage lasted for about 9 years. For many years, he worked on trenches. The patient minimizes if he abuses alcohol and denies using any street drugs. MENTAL STATUS EXAMINATION: This is a heavyset male. He was pretty cooperative. He was able to recognize the undersigned right away. He remembered the name. His mood is quite depressed. He is close to tears often. Affect is flat. He also seems quite nervous. His voice is somewhat shaky. The patient was able to give his birthday month and the year correctly and knew he was 48 years old. The patient knew he was in the hospital and who the president of the United States is. He was off on current time with the serial 7’s. He was not able to spell the word “money” and had quite a hard time spelling it backwards. He continues to have both auditory and visual hallucinations and some paranoid behavior. No acute agitation or aggression. ASSESSMENT: 1. Psychotic disorder, NOS. It does seem functional, especially with such a long history, and possibly, there is worsening of the symptoms with underlying delirium earlier. RECOMMENDATIONS: Today, I tried to go into my old files, but I was unable to find the evaluation that I completed for the Social Security office. Looking at his current picture, the patient does seem quite psychotic, and I think it is reasonable to treat him with any antipsychotics. Probably, he could benefit from a trial with antidepressants also, but I would hold using too many medications suddenly at this point, especially, as his physical status is so unclear. It does not seem there is any explanation why he was so unresponsive just yesterday. Targeting his psychosis, we will start him on Risperdal small dose and slowly got up on the dose tolerated. Thank you for asking me to see this interesting patient in consultation. CPT Code(s): ICD-10-CM Code(s):

Answer 1

Diagnosis is substance abuse (alcohol) and delirium tremens.

Substance induced Psychotic disorder with hallucinations

F01-F99-Mental, Behavioral and Neurodevelopmental disorders

F19 -Other psychoactive substance related disorders

F19.1-Other psychoactive substance abuse

F28 - Hallucinosis (chronic)

F19.951-Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder with hallucinations