**Identifying Information**
John Smith, [age 35], presents with a history of opioid use disorder, currently residing in a sober living facility. He is single and has no children. He reports a supportive relationship with his family and has a history of employment as a construction worker.
**ASSESSMENT**
**General Assessment**
Patient presents with opioid use disorder and is currently in a sober living facility. Key features supporting the diagnosis include a history of opioid use, withdrawal symptoms, and cravings. Biopsychosocial factors contributing to vulnerabilities include a history of trauma and social isolation. Protective factors include stable housing, family support, and motivation for treatment. Priority areas for treatment include medication-assisted treatment, individual therapy, and relapse prevention.
**Nicotine Assessment**
Patient reports currently smoking 1 pack of cigarettes per day and is interested in quitting.
**Risk Assessment**
Pt is at chronically elevated risk of harm to self or others based on: history of suicide attempt, history of substance use.
These risks are mitigated by: willingness and motivation for treatment, future oriented thinking, sense of responsibility to family, stable housing, stable employment, family support.
**Diagnoses**
- Opioid Use Disorder, Moderate, in sustained remission, DSM-5 criteria met.
**PLAN**
- Labs: Urine drug screen, complete blood count, comprehensive metabolic panel.
- CONTINUE, Buprenorphine/Naloxone, 16mg/4mg, daily, start date 11/01/2024
- Individual therapy weekly, group therapy twice weekly.
- Family meeting scheduled for next week.
- Follow-up appointment in one week.
**REPORTED HISTORY**
**Past Medical History**
- Hypertension
**Medications**
- Lisinopril 20mg daily
- Buprenorphine/Naloxone 16mg/4mg daily
**Past Psychiatric History**
- Psychiatric Diagnoses: Major Depressive Disorder, Generalized Anxiety Disorder
- Psychiatric Hospitalizations: One psychiatric hospitalization for suicidal ideation.
- Outpatient treatment: Attended outpatient therapy for depression and anxiety.
- Suicide Attempts: One prior suicide attempt by overdose.
- Self Harm: None reported.
**Family History**
- Family Psychiatric Diagnoses: Father with alcohol use disorder.
- Family Psychiatric Hospitalizations: None reported.
- Family Completed Suicide: None reported.
- Family Substance Use: Father with alcohol use disorder.
**Social History**
- Living Situation: Sober living facility.
- Relationship Status: Single.
- Children: None.
- School: High school graduate.
- Income: Employed.
- Abuse, Neglect, Trauma: History of childhood physical abuse.
- Domestic Violence: None reported.
- Legal History: None reported.
- Access to weapons: Denies access to guns.
**Substance Use History**
**Treatment**
- Residential Treatment for Substance Use: Completed a 30-day residential treatment program for opioid use disorder.
- Outpatient Treatment for Substance Use: Currently attending outpatient therapy.
**Substance Use**
- Opioids: History of heroin use.
- Benzodiazepines: Occasional use in the past.
- Cocaine: Denies use.
- Methamphetamine: Denies use.
- Prescribed Stimulants: Denies use.
- Alcohol: Occasional use in the past.
- Marijuana: Occasional use in the past.
- Nicotine: Smokes 1 pack of cigarettes per day.
- Other: None reported.
**SUBJECTIVE**
**HPI**
Patient presents for follow-up of opioid use disorder. Reports cravings and withdrawal symptoms.
**Review of Systems**
Reports fatigue, anxiety, and insomnia.
**OBJECTIVE**
**Physical Exam**
General: NAD
MSK: no abnormal movements, no tics/tremors
Pulm: no increased work of breathing
**Mental Status Examination**
APPEARANCE: appropriately groomed, casually dressed, appears stated age
BEHAVIOR: Appropriate eye contact, facial expressions and posture. No psychomotor activation or retardation
COGNITION: alert, able to attend to conversation
FUND OF KNOWLEDGE: average for age/education on gross exam, no formal testing done
ATTITUDE: calm, cooperative, communicative
SPEECH: normal rate, rhythm, volume
LANGUAGE: fluent English with no gross signs of dysarthria
MOOD: anxious
AFFECT: anxious
THOUGHT PROCESS: coherent, linear, goal oriented. No derailment, flight of ideas, perseverance
THOUGHT CONTENT: no suicidal/homicidal thoughts, plans or intentions. No apparent delusions, ideas of reference, phobias, or preoccupations
PERCEPTIONS: no overt hallucinations or illusions
INSIGHT: intact
JUDGEMENT: intact
