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.
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
Food stamps
What would your follow up plan be?
i. Referral to a drug or alcohol rehab facility to learn new skills and behaviors through counseling and
behavioral therapies that would enable him to quit using alcohol.
ii. Referral to a Program of Assertive Community Treatment (PACT) team to monitor and encourage JG to be
compliant with his medication so as to improve his functioning in the community and reduce hospitalization.
iii. Encourage the patient to join a 12 Step of Alcoholics Anonymous group to help in his recovery from alcohol
addiction.
iv. Housing, family support (if possible), social support, spiritual support (since he said he attended church as a
boy), and financial support for the patient.
v. Recommendation for a long-acting antipsychotic injection (such as Abilify Maintena, if the patient tolerates
the oral Abilify) due to the patient’s history of non-compliance to his prescribed medications.
vi. Naltrexone would be prescribed for JG to quell his cravings for alcohol and help prevent relapse.
vii. The social worker assigned to the patient should make an effort to reconnect the patient to his family of
origin and children.
What would your follow up plan be?
Medication counselling
Lab tests- Liver function test,
Therapies- Individual, CBT,
Refer to AA, Rehabilitation
Link pt with- Social services- PACT,
Discuss safety plan with pt.