PATIENT NAME: Pamela C Brunfelt

DATE OF ADMISSION: 02/13/2006

DATE OF BIRTH:

AGE: 52

ADMISSION NOTE: 52-year-old women with complicated psychiatric disorder and drug dependence
presents due to decompensation associated with narcotic relapse.

CHIEF COMPLAINT: I relapsed within a couple days of discharge. I used two to three weeks 80 mg of
Vicodin. It was progressing.

HISTORY OF PRESENT ILLNESS: She has a complicated history of PTSD, bipolar, Dissociative Identity
Disorder, and in a likelihood Attention Deficit Hyperactivity Disorder further complicating this. She
seems to show significant improvement after Concerta was initiated. She was discharged in an improved
condition, however, within 2 days of discharge, she admits to relapsing onto narcotics and using them
for 2 to 3 weeks. She called requesting admission approximately 10 days ago, but was recommended to
go off the narcotics on her own. She has supposedly been off them for the past week.

CURRENT PROVIDER: Dr. Franks and Dr. Shaughnessy

PAST PHYSICAL HISTORY: Notable for multiple past psychiatric hospitalizations with complicated dial
diagnosis syndrome.

PAST PSYCH MEDICATIONS: Medications have been relatively stable with the addition of Concerta
during the last hospitalization, 36 mg at night. She has also been on Haldol, Effexor, Seroquel, and
Lamictal. She has been on numerous other medications prior to this as well.

PAST MEDICAL HISTORY: Notable for very labile hypothyroid situation. She also has recurrent
hyponatremia, chronic back pain, and has been suspicious for sleep apnea in the past as well.

CURRENT MEDICATIONS/ALLERGIES: Medications at discharge were:

1. Haldol 5 mg twice daily and 10 mg at night.

2. Concerta 36 mg in the morning.
3. Effexor XR 225 mg daily.
4. Seroquel 300 mg two tablets at night.
5. Verapamil ER 120 mg daily.
6. Ferrous sulfate 325 mg twice daily.
7. Aspirin 352 mg daily.
8. Atrovent two puffs every six hours as needed for shortness of breath.
9. Albuterol two puffs every six hours as needed for shortness of breath.
10. Lamictal 300 mg at night.
11. Vitamin E 400 mg daily.
12. Benztropine 1 mg 3 x daily as needed for ESPE.
13. Colace 100 mg daily.
14. Fish oil 1000 mg daily.
15. Synthroid 137 mg daily.
REVIEW OF SYSTEMS: Notable for fatigue, amotivation, and excessive sleepiness.

SOCIAL HISTORY: She has been living with her husband around Tomah. There have been some rather
severe stressors in the past, including; mental illness of her daughter, several physical illnesses due to a
car accident, and loss of grandchildren due to daughters apparent inability to care of them. Recently
she states that her marriage has been in trouble apparently due to her husbands frustration with
narcotic use.

DEVELOPMENTAL HISTORY: As per previous database.

HISTORY OF PHYSICAL/SEXUAL ABUSE/ASSAULT: As per previous database. Notable for alleged rape at
age 12.

FAMILY PSYCHIATRIC HISTORY: Notable for some severe dysfunction in daughter by her description.
Notable for alcoholism in father, sister, and grandfather. Notable for depression in father.

FAMILY MEDICAL HISTORY: As per H&P.

SUBSTANCE ABUSE HISTORY: Has been numerous, especially sedative medications such as
benzodiazepines and narcotics.

HISTORY OF LEGAL INVOLVMENT/VIOLENCE TO OTHERS: None known.

CURRENT LEGAL INVOLVMENT/STATUS (PROBATION, WORK-RELEASE, ED): None

PHYSICAL/NEUROLOGICAL EXAM: As per H&P.

MENTAL STATUS EXAM: Unlike previous hospitalization, patient is not glass eyed or even appearing as
tired or depressed as previous. She is alert and also not endorsing suicidality and not appearing to be
dissociated. She states that she has not been dissociating since her last hospitalization, which is different
from previous hospital admissions. She also is denying suicidal ideation at this time, though has had
urges to relapse back into narcotic abuse.

MINI MENTAL STATUS EXAM: Not preformed.

SUICIDAL IDEATION: Denying at this time.

HOMICIDAL IDEATION: None.

STRENGTHS: Is clean and sober over the last 10 days and there is some notable improvement perhaps
due to use of stimulant.

WEAKNESSES: Failing to cope at home.

PROBLEM LIST:

1. Over sedation, rule out sleep apnea (she has not yet gotten appointment for sleep study.)
2. Narcotic dependence and relapse.
3. Lactation presumably due to elevated prolactin.
PRELIMINARY ASSESSMENT:

AXIS I:
Posttraumatic stress disorder.
Bipolar disorder NOS.
Dissociative Identity Disorder.
Alcohol dependence, in remission.
Narcotic dependence, in active.
Benzodiazepine dependence, in remission.
Rule out sleep apnea.
AXIS II:
Deferred.
AXIS III
Hypothyroidism.
Chronic back pain.
Peptic ulcer disease, upper GI tract.
AXIS IV:
Marital problems and problems with primary support group, notably immediate family.
AXIS V: GAF CURRENT: 35 HIGHEST IN PAST YEAR: Unknown

PRELIMINARY TREATMENT PLAN:

1. Due to the lactation and presumable elevated prolactin, we will check that level but also try
discontinuing the Haldol at this time and observe for relapsing psychosis or not.
2. Continue Concerta 36 mg and consider increasing as needed.
3. Check T3 and T4 due to elevated TSH.
4. Send to dual recovery and NA groups.
5. Will try to set up outpatient sleep apnea study, PRI.

Mildred Sosa, MD
Gastroenterology Department
10/19/2017