Posted on 17 October 2009.
Wiki
+
Report Type: Eating Disorders Report
+
NEW PATIENT EVALUATION
+
Confidentiality and the limits thereof were discussed and informed consent was obtained. The patient agreed to undergo evaluation.
+
IDENTIFYING AND REFERRAL INFORMATION: The patient is a 38-year-old single Caucasian male who is 3 years post gastric bypass. He currently works full time. He was referred by Dr. XYZ for possible alcohol and eating issues.
+
PRESENTING PROBLEM: The patient is 5 feet 9-3/4 inches tall and currently weighs 219 pounds. This corresponds to an estimated body mass index or BMI of 31.6, which falls within the obese range. The patient was previously seen by the undersigned for gastric bypass evaluation in September of 2005. At that time, his weight was 286 pounds, which corresponded to an estimated body mass index of 41.12. He indicated that he believes that he is here because he has been increasing his alcohol usage. He feels that his eating has been okay and indicated that he gets in about 2 to 3 meals a day and a snack or two.
+
His current alcohol usage, however, is a minimum of 6 to 10 drinks a day, which has been daily for about the last year. He coordinates his increase in alcohol usage to the loss of his business about 1 year ago. He usually drinks Bacardi and Diet Coke but sometimes will drink beer. He indicated that, at times, he does drink and then he does not eat food.
+
HISTORY OF PRESENTING PROBLEM: The patient indicated that his highest adult weight was well over 300 pounds at the age of 24. His lowest adult weight was approximately 207 pounds, which was approximately 2 years ago. He has been slowly gaining and then maintaining his weight over the last 2 years. The patient right now is denying any overt binge eating. He denied any purging behaviors, use of laxatives, diuretics, diet pills, or syrup of ipecac. He does feel at times that he may overeat but is not sure if it qualifies as binge eating. This is something that will need to be continued to be investigated in future sessions. He indicated that his main triggers for eating are the same triggers for his drinking. These triggers are mainly boredom and depression. He has not received any eating disorder treatment in the past besides the gastric bypass evaluation by the undersigned and 2 to 3 sessions with Dr. ABC for binge eating prior to that.
+
PAST PSYCHIATRIC HISTORY: The patient denies any psychiatric hospitalization. He was on Zoloft in the past for depression but did stop that. He indicated that he currently does feel somewhat down and sad, mainly around the issue of his business failing. He indicated that he feels that he gets adequate sleep. He feels that his appetite is unchanged. He has had some difficulty with motivation and interest. He denies any history of self-harm or suicidal ideation. He denies any difficulty with concentration or memory. He denies any current signs or symptoms of anxiety, mania, or impulsivity.
+
In regard to chemical dependency issues, the patient indicated that he currently drinks 6 to 10 drinks a day at a minimum. He stated that there have been times in which he thought he only had 1 drink, but a friend had told him he downed 4 drinks. He indicated that he has not had any legal problems due to his substance use. He does feel that he has continued to use alcohol despite having some interpersonal problems. In the past, he had continued to use alcohol in situations in which it was physically hazardous and, at times, he indicated that he has had some difficulty with filling role obligations at home and with friends. He denied any difficulty with fulfilling major role obligations at work. He indicated that he feels very withdrawn and feels that he cannot stop drinking on his own.
+
In regard to criteria for substance dependence, he does indicate higher tolerance with the need for markedly increased amounts of the substance to achieve intoxication or desired effect. He has not had any withdrawal symptoms yet because he has not tried to cut down or abstain from alcohol in the last year. He also indicated that the alcohol is often taken in larger amounts and over a longer period than was intended. As mentioned above, he has a desire to cut down but has not had any actual attempts of cutting down yet. There are some important social activities that have been given up and/or reduced because of his alcohol usage. He also has been using the substance despite knowledge of having a persistent or recurrent physical or psychological problem such as depression and post gastric bypass issues that are likely to have been caused or exacerbated by his alcohol usage. We did discuss that at the least, he does have alcohol abuse and possibly alcohol dependence. We discussed that he will need chemical dependency treatment and he is agreeable to this. He has denied any use of drugs or tobacco.
+
PAST MEDICAL HISTORY: The patient’s primary care provider is Dr. XYZ. Current medical problems include diabetes, hypercholesterolemia, sleep apnea, obesity, hyperlipidemia, hypertension, and post gastric bypass surgery. Please see the chart for current listing of medication and dosage. Please see Dr. XYZ’s evaluation on ___, for full medical information.
+
ALLERGIES: He denied any allergies to food or medication.
+
FAMILY HISTORY: The patient is adopted, so he has limited information on family psychiatric and chemical dependency issues as well as family medical history.
+
SOCIAL AND DEVELOPMENTAL HISTORY: The patient indicated he was adopted as an infant and has been raised by his adoptive parents. He has 1 younger sister. He is married and has 2 children. He denied any difficulty with developmental milestones per his memory. In regard to issues of abuse before and after the age of 18, he indicated that he was constantly criticized and blamed for minor things. Before the age of 18, someone physically beat him and threatened to hurt, kill, or do something sexual to him. He is a high school graduate and currently works at KFC. He did have his own business but had to give that up a year ago. That is one thing that has been very difficult for him. He denied any legal difficulties. His social support system consists mainly of his family and some friends. In his free time, he is usually with his family. He indicated that he does have quite a bit of time off now with his new job, and he finds himself consuming alcohol during this time.
+
MENTAL STATUS EXAM: The patient presented as casually dressed and adequately groomed. He appeared his stated age. He displayed no unusual mannerisms, and his eye contact was appropriate. His speech was clear, coherent, and goal directed. He was oriented to person, place, and time. No evidence of a thought disorder was noted and none was reported. His overall mood appeared euthymic, and affect was appropriate to speech content. He denied any major emotional distress at the present time. He denied any past or current self-harm or suicidal ideation. He appeared to be of at least average intelligence, and his insight and judgment seemed adequate.
+
FORMULATION: The patient is describing signs and symptoms of possible binge eating. He also is describing signs and symptoms of depression, possible dysthymia, and either alcohol abuse or alcohol dependence. He has been diagnosed with depression in the past but is not taking any medication for this now. He also is consuming quite a large amount of alcohol on a daily basis. He indicated that he is very concerned about his alcohol usage and his mood, and he wants to learn new coping skills.
+
PROBLEM AREA #1: Alcohol abuse or alcohol dependence.
+
GOAL: To achieve sobriety.
+
INTERVENTION: Outpatient chemical dependency treatment via either First Step Recovery or Drake and Bureau. The undersigned will talk to Dr. XYZ to see if he would rather do the referral or if he would rather the undersigned did that.
+
PROBLEM AREA #2: Depression.
+
GOAL: To return mood to euthymic level and learn new coping skills.
+
INTERVENTION: Individual cognitive behavioral therapy with the undersigned. Also, the potential for medication.
+
PROBLEM AREA #3: Binge eating or overeating.
+
GOAL: To normalize eating patterns.
+
INTERVENTION: Individual cognitive behavioral therapy with the undersigned.
+
DIAGNOSTIC IMPRESSION:
+
AXIS I:
+
1. Maladaptive health behaviors affecting obesity.
+
2. Rule out alcohol abuse versus alcohol dependency.
+
3. Dysthymic disorder.
+
4. Rule out eating disorder, NOS, (binge eating disorder).
+
AXIS II: No diagnosis.
+
AXIS III:
+
1. Sleep apnea.
+
2. Obesity.
+
3. Diabetes.
+
4. Hypercholesterolemia.
+
5. Hyperlipidemia.
+
6. Hypertension.
+
AXIS IV: Psychosocial stressors: Moderate to severe, loss of business with grief over loss issues, increasing alcohol usage.
+
AXIS V: Current GAF = 58.
+
FOLLOWUP PLAN: The patient did agree to reschedule with the undersigned. He will be going on a trip for about 2 to 2-1/2 weeks next week and will make an appointment to be seen right after that. He is agreeable to obtaining chemical dependency services through either First Step Recovery or Drake. He also is agreeable to have the undersigned talk to Dr. XYZ about this issue. We also discussed that he will continue to work on food logging and discussing these issues in greater detail next time. He does know how to contact the undersigned during business hours as well as his family physician. He also does know how to contact Emergency Services if need be. He also did agree to talk to his significant other tonight and let her know that he indeed is consuming large amounts of alcohol, so that it is not a secret anymore. He indicated that he feels that she probably does know, but he is agreeable to bringing this out in the open.
+
SESSION TIME: 90 minutes.
Go to Source
