Case Study II

JG is a 32-year-old Hispanic male who has been referred by Clara Maass Medical Center ED to an outpatient clinic. He was taken to the hospital by the police for sleeping in the back doorway of a small shop. He says that he has been homeless for a month and exhausted the last of his money 3 days ago. He appeared dirty, his clothing were worn and ill-fitting, and his shoes were torn. He was underweight for his height and appeared older than his stated age. He was sweating and has a coarse tremor of his hands as he tries to hold a cup of coffee. His chief complaint is feeling depressed. His sister reveals that he was last on an antipsychotic medication. His psychiatric history includes many hospitalizations for bizarre behavior and for treatment for alcohol dependence. He has been without medication for several months. Medical history includes a cerebral concussion resulting from a fight, complaints of gastrointestinal problems, and infected blisters on his feet. Social history includes dropping out of high school in senior year, brief periods of working in a fast-food store, and arrests for loitering and shoplifting of six-packs of beer. When asked about his present social support networks, he says that his girlfriend left him when his money out 3 days ago. He has no contact with his two former wives or his four children and no contact with his family of origin. When asked about his spirituality, he says that he attended church as a boy but has not since then.

You already know this case study, I have answers the following questions. How would you prioritize the patient’s immediate needs? i.Review the patient’s bloodwork from Clara Maass Medical Center to rule out liver disease, other medical problems, deficient nutrients, and other substance use. ii.Assess the patient using the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) to ensure that the patient is not withdrawing from alcohol anymore. The patient may be given Librium, Serax, or Ativan depending on the CIWA score. Patients scoring less than 10 on the CIWA scale do not usually need additional medication for withdrawal. A score of 0 – 9 means there is absent or minimal withdrawal, 10 – 19 means there is mild to moderate withdrawal and more than 20 means there is severe withdrawal. If the patient has a history of liver disease, the patient would be given Serax. The patient would be given Librium if there is no history of liver disease. This is given to the patient to prevent the risk of seizures. The dosage of Librium or Serax would be based on the organization’s policy. iii. If the patient has not been started on Thiamine (Vitamin B1) from the hospital, start the patient on this medication upon admission to prevent a neurological disorder known as Wernicke–Korsakoff syndrome. iv. The patient would be assessed for depression. The assessment should ascertain whether alcohol withdrawal is the cause of his depressed mood or not. If JG meets the DSM-5 criteria for Major Depressive Disorder, then the patient can be started on a Selective Serotonin Reuptake Inhibitor (SSRI), for example, Prozac. The choice of Prozac is because of the patient’s history of medication non-compliance. v. Nutrition to ensure that the patient eats a well-balanced diet to replenish deficient nutrients and gain some weight since he is currently underweight. vi. Housing for the patient since he has been homeless for a month.

How would you prioritize the patient’s immediate needs? Treat alcohol withdrawal symptoms because he is prone to seizure He is at risk for suicide ideation due to his history – Presence of psychiatric disorder / Patient complaint of ‘’feeling depressed’’ – Sleep disturbance – Poor social support – Lack of relative Financial assistance due to unemployment and inability to care for self Affordable Housing – To prevent homelessness Employment Affordable Health insurance/medical care

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