Addiction Medicine Consult Note -- [Primary reason for consultation]

Reason for consultation

[List the primary reasons for consultation, including substance use disorders or other relevant issues.] For example: - Management of opiate use disorder - Stimulant use

History of presenting illness

[Describe the patient's presenting complaints including onset, duration, relevant treatments started, and any pending investigations. Include relevant substance use history and previous interactions with Addiction Medicine services.]

Substance use history

The following information was gathered from patient interview and from review of documented resources including MediTech, eHealth Viewer and Pharmanet. - ALCOHOL: [Summarize the patient's recent alcohol intake status.] - OPIOID: [Detail the patient's recent opioid use, including last use, current usage pattern, any IV drug use, methadone history, and goals for methadone dosage. Include any periods of abstinence and previous trials of other treatments.] - STIMULANT: [Describe the patient's stimulant use, including the amount used per day, method of use, and duration of use.] - BENZO: [Note any awareness of benzodiazepine contamination in the drug supply and whether the patient seeks illicit benzodiazepines.] - CANNABIS: [Summarize the patient's cannabis use.] - NICOTINE: [Detail the patient's nicotine use, including the number of cigarettes smoked per day and any previous use of nicotine replacement therapy.] - OTHER: [Note any regular use of other substances.]

Past medical, surgical, and psychiatric history

[List relevant past medical, surgical, and psychiatric conditions. Include substance use disorders, trauma, infections, and other chronic conditions.] For example: 1. Polysubstance use disorder: Benzodiazepines, cannabis, opiates, stimulants. Prescribed methadone but has not taken in several months. Known previous IVDU. Had previously been discharged from hospital due to safety concerns of heroin use with partner in the hospital environment. 2. Poly trauma from MVA in December 2023: Complex pelvic fractures treated operatively. Left tib-fib fracture treated operatively. L1-L5 transverse process fractures that were conservatively managed. 3. Possible PCOS. 4. MRSA positive in 2023. Sensitive to Vanco, Septra, clinda, and doxy. 5. Hep C, not treated 6. Asthma 7. GERD

Medications in community

[List current medications the patient is taking in the community setting or state 'None' if applicable.]

Medications in hospital

[List current medications administered in hospital with dosages and frequencies.] For example: - [Medication Name] [Dosage] [Route] [Frequency]

Allergies

[List known drug allergies or state 'NKDA' if none.]

Social history

[Describe patient's living situation, housing status, social supports, and financial assistance if applicable.]

Physical examination

[Document vital signs and relevant physical exam findings. Include general appearance, neurological signs, and any signs related to withdrawal or intoxication.] For example: - Temperature 36.7°, heart rate 99, blood pressure 100 with 67, resp rate 18, O2 sats 98% room air - She is curled up in bed, appears uncomfortable. She is rubbing her elbows. - Mildly diaphoretic. Pupils are slightly dilated for room light. Non tremulous. - Overall appears in moderate opioid withdrawal. Does not appear acutely intoxicated.

Investigations

[Summarize relevant laboratory and diagnostic test results, including blood work, urine drug screens, and imaging studies. Include dates and notable findings. (Write it in bullet point)] For example: Blood work done this morning shows white blood cells 23.1, hemoglobin 110, platelets 308. Lactate 1.5, sodium 134, potassium 3.9, urea 3.2, GFR 113. Has not had a UDS done on this admission. Last UDS on Medi-Tech from December 20, 2023 was positive for amphetamines, methamphetamines, MDMA, benzodiazepines, cocaine.

Assessment and plan

[Provide a concise assessment of the patient's conditions and a detailed plan for each issue. Include medication management, monitoring plans, referrals, and patient education.] 1. [Problem 1], [severe], [active] - [Management/treatment plan, including medication details, monitoring] - [Follow-up actions.] - [Mention any changes in medication or treatment strategy and the rationale behind them.] - [Include any communication with outpatient providers.] 2. [Problem 2], [severe], [active] - [Management/treatment plan, including medication details, monitoring] - [Follow-up actions.] - [Mention any changes in medication or treatment strategy and the rationale behind them.] - [Include any communication with outpatient providers.] For example: 37-year-old female admitted with lower leg swelling, cellulitis vs DVT, with a history of opioid and stimulant use disorders. 1. Opioid use disorder, severe, active She is keen to get restarted on methadone. We will initiate her back on her metadol-D, which she prefers, at 40 mg p.o. b.i.d.. We will keep her dose split b.i.d. while in hospital to monitor for sedation and plan to titrate in hospital then consolidate to once daily dosing prior to discharge. I have discontinued her morphine sulfate and added hydromorphone 8-16 mg p.o. q.1h p.r.n. for opioid withdrawal or pain. Depending on her demonstrated tolerance over the next couple of days, we will plan to increase her methadone to get her to a more therapeutic dose prior to discharge. Her outpatient OAT provider is Dr. van de Vyver through the Ponderosa clinic, whom I have CC'd on this dictation. 2. Stimulant Use Disorder, Active, Severe Unfortunately there are not strong evidence-based pharmacological options for the management of stimulant use disorder. Withdrawal management is mostly supportive. There is evidence for contingency management/ behavioral strategies but these are not readily available at our site. Hopefully these will become available with time. I will ask our substance use connections team to connect with this patient regarding available outpatient resources. 3. Nicotine use - I have added nicotine replacement therapy while in hospital and will plan to discuss anti craving medications during her admission.

Additional investigations

[List any additional investigations ordered or planned during the admission.] For example: I have requested a urine drug screen plus fentanyl as well as an ECG.

Follow-up

[Present contact and availability information in a concise list format. Use bullet points without complete sentences. Include essential contact details and hours only. Do not include disclaimers or apologies.] For example: - Addiction Medicine physician: Mon-Fri 0800-1600 - After-hours consult: 24/7 Addiction Medicine Support Line 1-778-945-7619 - Substance Use Connections: daily 0830-1630, community resource & discharge support - Contact Addiction Medicine service for questions