substance use history taking report

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Substance use history taking report

Introduction

Mr. A is a 68 years old Caucasian man who lives in a residential home. He was admitted to the ward two weeks before mainly for problematic alcohol use and plan is to detoxify him.

Mr. A is known to psychiatric services for 20 years and he was diagnosed as Korsakoff's psychosis, central pontine myelinosis and recurrent depression secondary to alcohol abuse. According to Mr. A, he had several admissions to the hospital due to alcohol problem. He used to live alone and was not able to care for him so was placed in present residential home.

Currently his problems are related to alcohol use. According to staff at this residential home, Mr. A was drinking everyday , non-compliant to his medications, trying to steal things from other residents rooms and was also caught by police couple of times, for shoplifting. He was also encouraging fellow residents to drink alcohol into the home. The staffs was finding it very difficult to manage him, hence this admission was planned.

Since his admission to the ward he is under care of multidisciplinary team. He is on alcohol detoxification regimen for severe