Addiction Medicine Consult

Valmis merkintä

Addiction Medicine Consult

Patient Identification: adult presenting for consultation about opioid use and treatment options.

History of Present Illness:
Reports nonprescribed opioid use over several months, with increasing concern about control and impact on work. Use is intermittent; last use was the prior evening. The patient describes cravings and one unsuccessful attempt to stop, without reported severe withdrawal. No overdose history reported. No current intoxication symptoms.

The patient is interested in treatment and has not previously received medication for opioid use. No recent imaging or other evaluation is reported. Function is affected by missed work and disrupted sleep.

Review of systems: Reports poor sleep; denies chest pain, shortness of breath, or current vomiting.

Substance Use History:
- Nonprescribed opioids, intermittent use; route and amount not established.
- Last use the prior evening; no reported overdose or severe withdrawal.

Past Medical History:
- No significant conditions reported.

Psychiatric History:
- No psychiatric diagnosis or self-harm history reported.

Medications:
- None reported.

Allergies:
- No known drug allergies reported.

Family History:
- Relative with alcohol-related problems.

Social History:
- Employed; housing stable; identifies a supportive friend.

Physical Examination:
- Vital signs: Not recorded.
- General: Alert, conversant; no apparent distress or intoxication.
- Neurological: No visible tremor; oriented.

Investigations:

Assessment & Plan:
adult with opioid use concerning for opioid use disorder, requiring fuller assessment.

1) Opioid use
- Discuss treatment options and arrange prompt clinical assessment for medication treatment.
- Provide naloxone education and overdose prevention counseling.
- Review withdrawal symptoms and urgent care precautions.
- Refer to counseling supports and follow up soon to coordinate care.

Havainnollistava tapaus, jossa potilastiedot ovat keksittyjä. Tämä ei ole oikea potilasasiakirja eikä kliinistä ohjeistusta. Tarkista jokainen merkintä oman vastaanottosi perusteella.

Merkinnän taustalla olevat kliiniset faktat

Uudelleen käytettävä pohjarakenne

Addiction Medicine Consult

[Date and time if mentioned]

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Substance Use History:
(hyphenated list)
- [Substance(s) used: type, amount, route, frequency, duration]
- [Date and time of last use]
- [Previous attempts at abstinence or treatment]
- [Withdrawal symptoms: type, severity, duration]
- [Overdose history: number, circumstances, naloxone use]
- [Complications related to substance use: medical, psychiatric, social]

Past Medical History:
(hyphenated list)

Psychiatric History:
(hyphenated list)
- [Diagnoses, hospitalizations, suicide attempts, self-harm, current symptoms]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Buprenorphine-naloxone 8-2 mg SL BID)

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- (e.g., Father: alcohol use disorder)

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Other substances: type, amount, frequency]
- [Living situation: who lives with patient, home environment, housing stability]
- [Employment/education status]
- [Legal issues: charges, probation, incarceration]
- [Support system: family, friends, community resources]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance: level of distress, signs of intoxication or withdrawal]
- [Neurological: orientation, tremor, asterixis, pupil size]
- [Other relevant systems: as indicated by history]

Investigations:
(hyphenated list)
- [Investigation results with units] (e.g., urine drug screen, LFTs, CBC, HIV, Hepatitis panel)
- (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary diagnosis or substance use disorder]

#) [Assessment as a numbered item for each substance or issue]
(Hyphenated list with each corresponding plan item on a new line)
- [Withdrawal management]
- [Pharmacotherapy]
- [Harm reduction]
- [Counselling]
- [Referrals]
- [Follow-up]
- [Return precautions]