wk5retract

Jane,

I just need you to do a psych assessment for this patient. He definitely has substance abuse issues but the focus should be on his mood disorder (Bipolar). Of course they go hand in hand. But the paper’s focus will be Bipolar Depression. If there is any information you need to answer questions just make it up. My professor will not know the difference. Thanks so much!

Data:

Therapist and James met to complete bio assessment. He presented with blunted affected and appeared anxious, guarded, withdrawn and irritable. He was observed to provide short one-word answers to questions, not elaborating on information and was a poor historian. He reported not feeling well due to PAWS. James refused family contact and did not want to speak with any family or supports.

Pt is a 40-year-old single male, with no children presenting for methamphetamine, cocaine and opiate abuse. Pt reports having 5.5 months of sobriety up until October of this year, and was engaged in AA, had a sponsor and lived in a recovery house. Pt reported he is seeking treatment because he is “sick of going through this”. He reports experiencing paranoia when using and coming off of methamphetamines. Pt has reported medical dx of GERD and asthma and is currently prescribed Prilosec and Prednisone, patient did not report whether he was compliant with his meds. He denied other medical problems at time of assessment. Pt reports psych dx of bipolar and depression, and is currently prescribed Lamictal and Lexapro. Pt reported he “doesn’t know” whether or not the medications are effective and may be open to seeing psych while he is here. Pt also identified having an addiction to porn, denied ever seeking help for this. He denied SI, denied past suicidal attempts and psych hospitalizations. Pt denies current legal problems but was arrested several years ago for burglary. He is currently unemployed, he reported he was laid off from his job as a sheet metal worker after using drugs at work and is currently collecting unemployment. Pt reports he was living in a recovery house up until his relapse, and has been staying with his mother for the past month. Pt reported he does not want to return there after treatment and will need assistance in developing an aftercare plan that includes housing.

Assessment:

D1 Pt reports experiencing PAWS, and appeared anxious, restless, guarded, reported “not feeling well”. He also reports experiencing some paranoid thoughts due to coming off of methamphetamine however denied having these currently.

D2 Pt reported a history of GERD and asthma, currently prescribed medication. He also reported he did not eat breakfast this morning but that his appetite has been “ok”

D3 Pt reported hx a of depression and bipolar, currently prescribed meds but unsure if they are effective. he denied SI. during assessment he presented as guarded, withdrawn and was difficult to engage in conversation as he was restless and irritable as well

D4 Pt presented as pre-contemplative as was guarded during assessment and he could not identify specific motivators for treatment other than his physical and mental discomfort.

D5 Risk factors for relapse include, unemployment, no stable housing, relapse history, limited supports identified, mental health problems, active PAWS, history with legal involvement

D6 Pt reports currently living with his mother, but does not plan to return there after treatment. He is unsure if he wants to return to a recovery house and will need assistance in developing an aftercare plan that includes stable housing

NRNP/PRAC6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint):

HPI:

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

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