Psychiatric Evaluation Instructions, Grading, & Example – 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. Inee 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 of Detox medications:ativan 7 day taper Trintellix 10 mg po daily, reassess after taper to Continue Testosterone Injection every Monday 09/20 2021 Conditions to monitor: worsening symptoms of withdrawals and BP Additional tests or orders: Pending admission order Continue to clinical programming as tolerated individual, groups and sessions Medication Assisted Treatment Education Health education provided to the patient regarding medication-assisted therapy, lifestyle modification, medication side-effects, and adverse reactions, patient safety, the current level of care, and changes in the treatment plan; the patient verbalized understanding and is in agreement with the treatment plan.
Mia S.Oct 5, 14:19
Severity Rating – Dimension 6 Recovery/Living Environment: 2 – Moderate. Unsupportive environment, but able to cope with clinical structure most of the time.
Rationale for Dimension 6 Rating:
Unsupportive environment
Treatment Plan: Labs/ EKG, Initiate/ Continue Detox Protocol
Mia S.Oct 5, 14:19
single never married, no children, 2015 sexual assault, reported. sexual , explloited verbal abuse mentally, physically and emotional abuse in Kings county Brooklyn NY, reports has PTSD from trauma
Mia S.Oct 5, 14:19
Safety Precautions : Q15
Client/Guardian Response: Understands information and is competent, The Patient indicates he/she understands
Assets: Good Interpersonal Skills, Well-educated, ADL’s Independent, Available Support System, Verbalizes Needs, Cognitively Intact, Physically Healthy
Limitations: Other
Medication reconciliation completed with patient (areas discussed included duplication, omissions, interactions and the need to continue current medication.): Yes
Discussed the risk, benefits, and side effects of medication: Yes
Discussed the diagnosis, treatment plan/rational treatment : Yes
Was this a Tele-Session?: No
Dim 6: Environment
Social History and Family History of Substance Abuse, Mental Illness and/or Suicide Ideation : denies
Children: 0
Legal Problems: denies
Number of Arrest: 2
Housing Problems: Lives with her sister
Sources: –
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8 pages / 2200 words (Double spacing)
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