6394 Revision Order Within 6 Hrs
ltdprinwival
6650_client_1_week_2_MG.docxI. Identifying Information Client one MG 22 yr old SWF caucasian
Marital Status:
Single
Allergies/Drug Reactions:
No Known Allergies/NKA
Current Medications
☑ No medication
II. Chief Complaint
Heroin and crack cocaine abuse
III. History of Present Illness: (Include a history of present illness, including onset, precipitating factors and reason for the current admission, signs and symptoms, course, and the results of any treatment received.)
22yo SWF with history of heroin and cocaine abuse presenting for her 4 or 5th treatment program, endorses depression and anxiety. Has trouble with sleep, concentration, motivation, feels hopeless and depressed, worries about her dad who is suffering with Parkinson's disease and dementia and she was caring for him prior to coming to treatment, but had also been in and out of detoxes.
IV. Past Psychiatric & Substance Treatment History: (Including prior precipitating factors, diagnosis, course and treatment) (Has the patient been chronically ill? Continuously/repeatedly? How severely has the past illness/treatment interfered with the patient’s development and/or adjustment? Are there persistent symptoms/signs/behaviors that must be addressed and treated in order to favorably impact on the future psychiatric course? What medications or supports helped him/her improve in the past? Are the same resources available to impact on the patient’s treatment during this episode)
Been in treatment in the past, longest period of sobriety is 5 months. Not been seen by psychiatrist before or been inpatient psych. Has been on Prozac and Zoloft in the past but admits to not giving them enough time to notice benefit.
V. Pertinent Past Psychiatric History: (check all that apply)
• Failure of outpatient/IOP treatment
• H/O recurrent problems with psycho-active substances
VI. Background & Social History: (Include family, educational, vocational,occupational and social history)
Grew up with parents who divorced when she was 7, father was a CEO and mother is a flight attendant; father now age 60 and has Parkinson's disease and dementia. Brother also an addict now living in sober living and sober for past month. Completed through 9th grade, no work history. Has a partner of 2 years.
VII. Medical/Surgical History:
none
VIII. Seizure History:
none
IX. Head/Trauma History:
none
X. Trauma/Abuse History:
raped, physical abuse
XI. Psychosocial/Development/Family History Overview:
Brother heroin addict Family members with depression, anxiety, PTSD, alcohol abuse
XII. Previous History Suicidal/Homicidal Ideation/Plan:
denies
XIII. Current Suicidal/Homicidal Ideation/Plan:
denies
XIV. Mental Status Exam: (Check all Symptoms Present)
A. Appearance:
Casually Dressed , Relaxed , Age appropriate , Appropriate
B. Speech
Fluent Speech , Normal
C. Behavior:
Calm , Good Eye Contact
D. Attitude:
Cooperative
E. Mood:
Anxious , Dysphoric
F. Affect:
Depressed , Anxious
G. Self and/or Others Agressive/Destructive Thoughts and Behaviors:
Suicidal Ideation
No
Homicidal Ideation
No
Self Destructive Behaviors
No
H. Thought Process:
Coherent
I. Thought Content:
• Denies
J. Vegetative Signs:
XV. Cognitive Assessment:
A. Orientation:
WNL
B. Last Five Presidents: Able to Recall:
C. Learn Three Objects (e.g. 3 feathers, 11 envelopes, 29th Avenue)
D. Digit Span (e.g. 9 6 4 6 1 7)
Number forward Correctly
Number backward Correctly
E. Repeat Three Objects (See “C”)
F. Intelligence Estimate:
Average
G. Memory:
1. Immediate Recall
Intact
2. Short Term
Intact
3. Long Term
Intact
4. Concentration
Intact
5. Attention
Intact
H. Impulse Control:
Average
I. Introspection:
Average
K. Judgement:
Employed
XVI. Strengths & Assets: (check all that apply)
• Cooperative
• Communication skills
XVII. Liabilities/Barriers to Recovery:
XVIII. Diagnostic Impressions/Diagnosis:
DSM V Diagnosis
Diagnoses
F11.20 Opioid use disorder, Severe,F15.20 Amphetamine-type substance use disorder, Severe,F32.9 Unspecified depressive disorder,F41.1 Generalized anxiety disorder
Medical Conditions:
None
Psychosocial Stressors:
• Problems with primary support group
• Problems related to social environment
• Problems with sexual abuse / trauma
Need for Suicide Precautions:
Yes
☐
No
☑
XIX. The patient has been fully informed by the psychiatrist about the possible risks and probable benefits of their treatment. The patient has expressed to the psychiatrist an understanding of the explanations that were provided by the psychiatrist.
Yes
XX. Justification for Detox, Intensive Inpatient, Residential Treatment or PHP Treatment:
• Acute history of psychoactive substance abuse
• Acute history inability to maintain any type of long-term absence from psychoactive substances
XXI. Treatment Recommendations:
• PHP/Day-Night
• Medication Management
• Individual Psychotherapy
• Group Psychotherapy
• Psychoeducational Groups
• Aftercare Plan
XXII. Psychopharmacologic Interventions:
1. Start Lexapro 10mg qhs depression, anxiety 2. Start Naltrexone 50mg qhs cravings 3. Increase Gabapentin to 300mg tid 4. Continue Vistaril 50mg tid prn anxiety
Risks, benefits, side effects, and dosage schedule explained to patient:
Yes
Client verbalized understanding of teaching:
Yes
Follow-up:
Next week
On this examination, the patient demonstrated signs suggestive of Tardive Dyskinesia. The potential risks and long term consequences of this disorder, and treatment alternatives, were discussed and understood by the patient/guardian.
No
XXIII. Physician Certification of Need for Admission: As a physician duly licensed to practice medicine, I hereby certify that treatment is medically necessary. I certify that treatment could not be effectively provided at a lesser intensive level of care and that the patient is able to participate in all aspects of the treatment program. All treatment services will be provided to the patient under my direction and under a written plan of care. Having completed this Physician Initial Certification of Need for Admission, I do authorize and order the patient’s admission.
