The Veterans Administration at this point
gives me a mental examination, I obtain it
from my medical records, some of it seems
good and other parts of the exam, not so
good.
Appearance: casually dressed, well groomed.
No psycho motor agitation or retardation.
Alert and oriented X4.
Speech: normal rate, volume. No FOI.
Mood and affect: "pretty good", appropriate to situation and congruent'
Thought process: logical and linear.
Thought content: denies AVH; denies SI/HI.
Cognitive functions:
- Attention and concentration: intact.
- Memory: intact recent and remote.
- Insight and judgment: fair.
Alcohol dependence/withdrawal; nicotine dependence.
Axis III- HTN, alcoholic cardiomyopathy, DVT with subsequent anticoag therapy, ED, COPD.
Axis IV- limited recovery skills, lack of social support, unemployed.
1. Alcohol Withdrawal- will arrange benzodiazepine taper 25mg 1-2 capsules as needed q6 hrs for symptom of alcohol withdrawal.
2. Alcohol dependence- Based on history of dependence, significant tolerance,multiple failed attempts to control use, patient remains at risk for relapse with possible dangerous consequences without further 12 step recovery involvement and/or structured treatment with supportive living environment. Case manager appointment is pending.
Recommend 90 meetings in 90 days and obtaining 4 contacts within one week.
ASAM Admission Criteria:
1.Withdrawal- moderate risks- benzo taper; will monitor response to medications.
2.Biomedical- stable
3.Emotional/Behavioral/Cognitive- stable
4.Readiness for change- states desire to make significant changes in his life.
5.Relapse Potential/Continued Use- stable while in structured environment; at risk w/o developing and adhering to program of recovery.
6.Recovery Environment- poor.
My self prognosis is: I am a sober veteran and
plan on staying that way, no matter what.
Author: Recovering Alcoholic
Alden Morrison
