Cocaine Case Summary

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The patient is a 61 year old male who presented to the ED with depressive symptoms, crack cocaine use, and alcohol use. The patient denies suicidal ideation, homicidal ideation, and symptoms of psychosis. The patient is calm and cooperative. The patient reports no withdrawal systems. During the time of assessment the patient was sleep and was awakened by clinician. The patient appears drowsy and has a flat affect. The patient reports smoking $700 of Crack Cocaine the past 2-3 days. The patient most recent drug screens confirms that cocaine is currently in the patient system. The patient reports drinking up to two 40oz beer beverages daily. The patient reports he has been drinking alcohol since he was 11 years of age. BAC was 0.01 in lab report. The patient reports drug use and alcohol use was not an attempt to harm himself. The patient reports that he as been suffering from insomnia for the past 3 days. Furthermore, the patient his depressive symptoms as irritable, tearfulness, worthlessness, hopelessness, anhedonia, fatigue, and mood swings the last 1-2 weeks. The patient states, "I am anger because I am sad." The patient reports that he is still struggling with the lost of his mother a year ago and a recent break up with his girlfriend of 42 years; which the break-up was about 4-5 months ago. Also, the patient reports that his truck was stolen from him by a individual he was about to give a ride. The patient reports in this incident the individual stole and blew-up his car. The patient has minimal eye contact during the assessment. the patient frequently falls asleep. The patient reports…show more content…
The patient has voluntarily choose to undergo inpatient hospitalization for safety and stabilization. TACT consult Dr. Osborne and his deposition is to continue treatment for dual diagnosis of Unspecified Depressive Disorder, Cocaine abuse, and Alcohol Dependence. TACT will assist ED doctors by seek appropriate place for the

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