Assignment Type: PowerPoint Presentation
Instructions
The link to the file:
Case Presentation – NSG-535-IKB – Adv Prac in Psych_MH Nurs I.html
Patient states”I feel a lot rested today“
History of Present Illness:
09/15/2021: Patient is a year-old white female admitted to Orlando Recovery Center for the treatment of alcohol use disorder severe and alcohol withdrawal. UDS results: NEG, BAL: 0.400. She is seen for initial psych eval today. she is currently on an ativan taper day 2 of 7. Reporting she is tolerating her taper well, along with her other medications. She denies any side effects or adverse effects. Pt reports last use was 9/12/21 and she drink 20 glasses over a period of 2 days. Pt endorsed substance of choice is wine, her regular quantity of use is 20 glasses of wine in 2 days. In the last 2 month it was once or twice per week, it has progressed to daily in the last month. She reports she works of Apple Support from Home. She would drink sometimes while she is working. 08:33 am his blood pressure is elevated 171/97, nursing will do a Manuel BP and document in Avatar. Manuel BP done at 11:49 BP 138/101 HR 100. Clonidine 0.1 mg po x 1 dose now and repeat bp and document in Avatar. Manuel BP x 3 days. Psychiatric Evaluation: She has poor family support. she is currently living in Altamonte with her sister because there was a family fight, police were called and she and her sister were kicked out of her parents house. She is currently in the process of transitioning from a female to a male as per patient. She had a bilateral mastectomy 2018 as per patient. He is calm and soft spoken, speech is clear and concise. He is able to make his needs known. **I have read the HPI below and I concur with the findings”
Patient is a 37 year-old black female admitted to Orlando Recovery Center for the treatment of alcohol use disorder severe and alcohol withdrawal. UDS results: NEG, BAL: 0.400. Progression of use, tolerance: Pt endorsed substance of choice is wine, her regular quantity of use is 20 glasses of wine in 2 days. In the last 2 month it was once or twice per week, it has progressed to daily in the last month. She reports she works of Apple Support from Home. She would drink sometimes while she is working. She says her drinking varies, sometimes she drinks after work, on her day off and sometimes on the weekend.She reports her parents kick her sister and her out of the house after her double mastectomy. She is in the process of transition from a female to a male. She reports home life became hostile and physical and the police were called. she is currently living with her sister in Altamonte Spring. She says this escalated her drinking due to family stressors. Pt report using since age 20, and her current period of use has lasted 6 months amount of time. Pt reports last use was 9/12/21 and she drink 20 glasses over a period of 2 days. Denies SI/HI at this time Current withdrawal symptoms: anxiety 5/10, depression 2/10, nausea, chills, sweats, low appetite, insomnia High Risk Activities:working under the influence. Prior and current history of withdrawal seizures: Pt denies history of overdose, denies history of withdrawal seizures, denies history of respiratory arrest, and denies history of DT’s. DSM-V criteria – patient fulfills DSM-V Criteria for substance use disorder severe. Previous treatment and level of care: Previous community recovery experiences: Longest sobriety period: She was 8 months sober and clean, she was going AA meetings and she was attending intensive outpatient clinic Current medical problems: denies Current or Past surgeries: Double Mastectomy 02/17/2021. Several tattoos noted and 2 surgical scars around breast noted Current medications: Testosterone inj and Trintellix 10 mg po every day Drug screen test results: negative for all other substances Current blood alcohol level: 0.400
Diagnosis: (F10.20) Alcohol use disorder, severe
Diagnosis: (F10.239) Alcohol withdrawal without perceptual disturbances
(Z86.59) History of schizophrenia
Let me give you information first.
Diagnosis: (F31.9) Bipolar I disorder, current or most recent episode unspecified
(F63.3) Trichotillomania (hair-pulling disorder
(Z90.13) History of bilateral mastectomy
I need a Power point and a Psychiatric evaluation. I need you to use this information for both
Is this something you can do
ASAM Level of Care Recommendations: 3.7WM Inpatient Detox
PLAN:continue to detox LOC Continue admissions protocol Description
Sources: –
Citation Style: –
8 pages / 2200 words (Double spacing)
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