CIWA/ OUD Patient

Progress Note

Patient X

55-year-old male
PMHx: Alcohol use disorder (AUD), opioid use disorder (OUD), cocaine use disorder, hyperlipidemia (HLD), COPD, major depressive disorder (MDD), prior COVID

Presentation: Progressive dyspnea over 2–3 months with lower extremity edema, concerning for CHF.

Follow-up TTE: Normal LV function, EF 65%, mild diastolic dysfunction.

Status:

• Room air

• Independent mobility

• On C. diff isolation

• Telemetry: NSR/NST

Plan

# Alcohol use disorder / Opioid use disorder / Cocaine use

• Addiction medicine following, appreciate input

• Patient currently on CIWA with scheduled and PRN benzodiazepines

• Continue scheduled and PRN benzos

• Continue thiamine and folate

• PRN hydroxyzine and clonidine

• Melatonin for sleep

• Plan for IM naltrexone on discharge

• Ongoing monitoring

# Dyspnea, resolved / Lower extremity edema

• Likely multifactorial, partly due to hypoalbuminemia

• TTE: normal LV function, EF 65%, mild diastolic dysfunction

• Continue monitoring

# Hypokalemia

• K today: 3.1

• Potassium replaced

• Will monitor response and repeat BMP

# COPD

• Continue DuoNeb

Labs / Electrolyte Abnormalities

• Hypokalemia (K 3.1, replaced)

• Hypercalcemia

• Hyponatremia

• Thrombocytopenia

Comorbidities on Admission

• AUD, OUD, cocaine use disorder

• COPD

• HLD

• MDD

• PMH COVID

Secondary Diagnoses During Hospitalization

• Hypokalemia

• Hypercalcemia

• Hyponatremia

• Thrombocytopenia

Orders

Diet: Regular
VTE PPx: Enoxaparin 40 mg q12h

Medications:

• Thiamine 100 mg daily

• Folic acid 1 mg daily

• Famotidine 20 mg daily

• Enoxaparin 40 mg q12h

• Escitalopram (Lexapro) 5 mg daily