6394 Revision Order Within 6 Hrs

Admit Date/Time:

February 25, 2019 at 12:00 AM MST

Admission Type:

Voluntary

☐yes

Involuntary

☐

Marital Status:

Single

Allergies/Drug Reactions:

No Known Allergies/NKA

Current Medications

☑ No medication

II. Chief Complaint

Meth 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.)

23yo WF with extensive substance abuse history starting at age 10 presenting for her second treatment program, but first program since being released from prison after her 3 year stint. She denies depression or anxiety, but upon further exploration seems she struggles with focus/attention, is always fidgeting and can't sit still, passed HS by doing all the work while in class and then getting high at night.

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)

Done one previous program in 2016 and was sober for about 4 months. Was sober for the 3 years in prison and relapsed 3 months after she was released. Never used IV. Has never seen psych or been inpatient, never had SI or SA.

V. Pertinent Past Psychiatric History: (check all that apply)

• H/O recurrent problems with psycho-active substances

• H/O legal problems

VI. Background & Social History:  (Include family, educational, vocational,occupational and social history)

Grew up with parents who divorced when she was 4 and she split her time between Mom and Dad's house 50/50. Graduated HS, has some college credit that she received while in prison. She was working call center in prison and after release; has also gotten certificate to do hair but did that for a little bit and didn't like it.

VII. Medical/Surgical History:

none

VIII. Seizure History:

none

IX. Head/Trauma History:

none

X. Trauma/Abuse History:

none

XI. Psychosocial/Development/Family History Overview:

Half sister possibly Bipolar, ADHD

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:

Disheveled , Casually Dressed , Age appropriate , Appropriate

B. Speech

Fluent Speech , Normal

C. Behavior:

Tearful , Good Eye Contact , Manipulate , Other/Comments:: Fidgety, restless

D. Attitude:

Cooperative

E. Mood:

Anxious , Content/Context Appropriate

F. Affect:

Full Range

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:

Crying Spells , Anhedonia , Anergia , Decreased Concentration

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:

Above Average

G. Memory:

1. Immediate Recall

Intact

2. Short Term

Intact

3. Long Term

Intact

4. Concentration

Intact

5. Attention

Intact

H. Impulse Control:

Below Average

I. Introspection:

Average

K. Judgement:

Employed

XVI. Strengths & Assets: (check all that apply)

• Physical Health

• Support Family

• Communication skills

XVII. Liabilities/Barriers to Recovery:

XVIII. Diagnostic Impressions/Diagnosis:

DSM V Diagnosis

Diagnoses

F15.20 Amphetamine-type substance use disorder, Severe,F41.9 Unspecified anxiety disorder,r/o ADHD