36C10X19Q0200-012.pdf

Patient: Provider: Request ID:

Review Findings Special Instructions (extracted from the spreadsheet or other documentation provided by

VISN):

Veteran with history of chronic pain issues, depression, and anxiety presented to Urgent Care

Clinic with c/o nausea, vomiting, and cough. He was admitted to medical observation unit. Following the observation stay he was admitted to the acute psychiatric unit for medication adjustment. He discharged from the acute psychiatric unit on . The psychiatrist under review completed a psychiatric evaluation on during the observation stay and continued to see the Veteran for pharmacy management during his inpatient acute psychiatric hospitalization and following his discharge. Was the standard of psychiatric care met for the Veteran's mental health issues for the timeframe under review? Was medication regimen appropriate and within standard for mental health and chronic pain issues?

Brief clinical case summary:

This patient was a year old male veteran who contacted the VA on reporting multiple medical complaints including abdominal pain, weight loss, diarrhea, sweating, and rectal bleeding.

He was advised to go to the VA Urgent Care for evaluation. The patient was evaluated by the practitioner on and was diagnosed with major depression, post-traumatic stress disorder

(PTSD), and pain disorder associated with both psychological factors and a general medical condition (psychalgia).

He was transferred to a psychiatry unit and adjustments were made to his medications. On discharge from the medicine unit, it appeared that the patient had responded to symptomatic interventions but there was no clear etiology for his complaints. The plan for transfer to psychiatry was for medication adjustment. Medication adjustments were made including increasing venlafaxine, hydrocortisone for "supplementation", testosterone for hypogonadism and initiation of methylphenidate.

The patient was next seen by the practitioner on . The patient felt that the hospitalization had been of benefit and requested an increase in his methylphenidate. He gave the practitioner a version of events related to an incident where he was perceived to have barricaded himself in his room at the hospital. He denied this. He requested to try a benzodiazepine other than lorazepam

It was agreed to try Xanax.

On , he was seen by the practitioner for an outpatient appointment. His medications included Xanax, amitriptyline, hydrocortisone, methylphenidate, mirtazapine, morphine sulfate instant release and sustained release (IR and SR), ondansetron, temazepam, testosterone, and venlafaxine. He was described as stable overall and no medication changes were made. There was no indication that he was posing a risk of harm to himself or others.

On , he was seen for another outpatient visit. He was judged to be slightly worse although the details leading to this assessment were not clear from the progress note. No medication changes were made.

On , , and the patient was described as stable and no changes were made to his medication regimen. On he contacted the practitioner by secure messaging asking for increased pain medication. He stated that he was having difficulty related to Lyme disease. The psychiatrist/practitioner increased the morphine IR without seeing the patient.

The following day the patient again contacted this practitioner by secure messaging and requested an increase in methylphenidate stating that his stomach was bothering him and he did not want to consume more caffeine and thus was requesting an increase in his methylphenidate dose. This change was also made.

On , the patient was described as unchanged at his appointment with no change made to medication.

On , the patient reported feeling a bit better but had been out of his house for over a week due to a problem with his home. It was noted that he continued to have dental problems similar to those he had reported at the preceding appointment.

On , the patient reported feeling better after being out of his house while a problem with mold was being addressed. It was felt that he was stable overall and no changes were made to his medication.

On , he reported feeling upset about the quality of care he was receiving for dental problems outside the VA system. However, he was again described as stable and no medication changes were made.

On , the patient reported that he had a stroke with right-sided weakness and word finding difficulty. He was seen at a community hospital and started on Coumadin. He also reported continued problems with his housing, and frustration related to this.

On , the patient was seen by the practitioner; the patient brought a discharge summary from recent care based on his multiple medical issues including cardiac concerns and stroke related issues. The practitioner noted that there appeared to be significant confusion related to the patient's diagnosis and plan for further evaluation of his medical condition. No changes were made to his medication.

On , the patient reported break through pelvic pain and left arm pain. He also reported continued dental problems despite having a tooth pulled. He continued to have problems with his housing. A decision was made to again increase his morphine SR.

Primary Diagnosis: major depression

Secondary diagnoses: PTSD, pain disorder

Surgical Procedures: N/A

Overall Evaluation

Practitioner under review:

Based on your review of the clinical record, was the standard of care met by the practitioner under review?

Standard Not Met

Please summarize your assessment of this case by giving your rationale for the determination above. Please include any comments that you think are relevant to your findings. Please state references, standard practice guidelines or other resources that were used in making your final determination.

There were multiple concerns in this case:

The management of pain medications in this case by a psychiatrist in the context of a patient with complex and serious medical conditions in the absence of physical evaluation was not consistent with standards of care in the reviewer’s experience and opinion.

There was no consideration given to decreasing medication doses at any point. The first dose increase of opiates during the dates under review was based on a secure message without medical evaluation or adequate clinical justification.

The second dose increase was in response to complaints of breakthrough pelvic and left arm pain. The lack of medical evaluation in this instance was particularly concerning in light of this patient's documented cardiac and stroke issues.

Additionally the use of stimulant medication was not consistent with standards of care.

While the practitioner listed several references including his own publication, there was no clinical justification for the addition of a stimulant or the later increase in dose. The increase in dose followed a request by secure messaging. The patient's request suggested that he may have been having problems with sedation but this was not considered and an increase was made.

This patient had serious medical issues and the care provided by this psychiatrist/practitioner did not appear to adequately consider the need for appropriate medical evaluation and care.

The standard of care was not met.

Reviewed by:

Specialty: Psychiatry Date completed: