6635.PWk9Assgn

Jane,

Another Psych eval. Just do exactly what you’ve been doing because they are turning out great. We already did a patient with Bipolar and an alcoholic, so now I found a patient with Schizophrenia. This patient grew up in a broken home in an impoverished area of Camden, New Jersey. You can mention that if you want. And as always, you can make up information if you want to. Thanks!

Writer met with Shane to complete bio assessment. Pt calm and cooperative, alert and oriented x 3. Pt engaged in assessment and willing to answer all questions. Pt has extensive psychiatric history and is a poor historian with tangential thought processes and circumstantial speech.

Shane is a 25-year-old African American male. Pt admitted to RCA to treat crack-cocaine abuse. PT also reported using 1 bag of fentanyl (first use ever) before being admitted. Pt also regularly smokes Marijuana. UDS positive for COC, FENT, THC. Pt currently detox status but as of now will not be receiving a taper. Pt presents with no physical withdrawal symptoms. Pt denies any pain, discomfort, or anxiety. Medical history includes a torn rotator cuff and “a few herniated discs” from a 2019 MVA. Pt does not take any medications for medical reasons. Psychiatric hx includes Paranoid Schizophrenia, Bipolar Depression, and PTSD. Psychiatric medications include Depakote 100mg QHS, Risperdal 2mg QHS, Cogentin 1mg BID, and Haldol 5mg BID PRN. Pt denies current suicidal ideation and homicidal ideation but has history of both. Pt denies hallucinations. Pt was involuntarily admitted to inpatient psych 2 weeks ago for threatening to beat up his father and burn down his house.

Pt denies any unhealthy behaviors involving arson, gambling, or sex. Pt stated that he does have current legal issues but did not want to elaborate. Pt currently not working and collecting unemployment. Pt states that he is financially stable with unemployment. Pt is eager to find a job after treatment although injuries from MVA prevent him from being able to work certain jobs. Pt has been living in two separate places, with his father and his girlfriend (mother of his 7-month-old son) and he has not been getting along with either. Pt plans on staying 7 days only. Pt reports that he is not interested in IOP but is willing to go back to AA/NA. Pt is planning on reaching out to his grandmother and his uncle to see if they can help him with his living situation.

D1: Pt admitted to RCA on detox status but is not receiving a taper. Pt has been abusing crack-cocaine which does not require pharmacological detoxification. Pt used fentanyl only one time. presents with no physical withdrawal symptoms. Pt denies any pain, discomfort, or anxiety related to withdrawal.

D2: Pt was involved in an MVA in 2019. Pt suffered multiple disc herniations and torn rotator cuff. Pt does wear a lower-back brace as needed. No prescribed medications for medical issues

D3: Pt diagnosed Paranoid Schizophrenia, PTSD, Bipolar Depression. Pt prescribed Depakote 1,000mg QHS, Risperdal 2mg QHS, Cogentin 1mg BID, and Haldol 5mg BID PRN. Pt has multiple instances of both SI and HI in his history but denies any current issues. Pt denies hallucinations. Pt reports multiple inpatient stays. Pt was admitted involuntarily 2 weeks ago for threatening his to hurt his father.

D4: Pt presented as pre-contemplative during assessment. Pt is only willing to stay 7 days. Pt also not interested in outpatient counseling. Pt focused on finding work, spending time with his son, and fixing the relationship with his girlfriend.

D5: Risk factors include extensive psychiatric history and inability to control his behaviors, relapse history, lack of job opportunities, and lack of therapeutic residence in which to reside.

D6: Pt is willing to stay in treatment for one week. Pt not interested in outpatient therapy but is interested in trying AA/NA once again. Pt currently does not have a stable living situation. Pt wants to reach out to extended family members for help. Pt willing to accept help from treatment team.