Follow Up Note

**Identifying Information** Patient Name: John Smith Date of Birth: 01/01/1980 Date: 1 November 2024 **ASSESSMENT** **General Assessment** Patient presents for follow-up of substance use disorder. Patient reports continued use of alcohol and cannabis despite previous interventions. Patient reports feeling overwhelmed by stressors at work and in his personal life. Patient is motivated to reduce substance use but struggles with cravings and triggers. Biopsychosocial factors contributing to vulnerabilities include a history of childhood trauma and social isolation. Protective factors include a supportive family and a strong desire to improve his health. Priority areas for treatment include relapse prevention, coping skills training, and addressing underlying trauma. **Nicotine Assessment** Patient denies current use of nicotine products. (Data from prior encounter) **Risk Assessment** Pt is at chronically elevated risk of harm to self or others based on: History of alcohol use disorder and cannabis use disorder. These risks are mitigated by: Willingness and motivation for treatment, stable housing, and family support. **Diagnoses** - Alcohol Use Disorder, moderate, in sustained remission. (DSM-5 criteria: Meets criteria for moderate alcohol use disorder in the past, currently in sustained remission for over 12 months.) - Cannabis Use Disorder, mild. **PLAN** - [Planned investigations.] - Medication plans: - CONTINUE, Naltrexone, 50mg daily (start date: 10/01/2024) - Psychotherapy plans and strategies: Continue individual therapy with a focus on relapse prevention and coping skills. - Planned family meetings & collateral information, psychosocial interventions: Schedule family therapy session to address family dynamics and support patient's recovery. - Follow-up appointments and referrals: Schedule follow-up appointment in two weeks. Refer to a support group. **SUBJECTIVE** **HPI** Patient reports continued use of alcohol and cannabis. Reports feeling overwhelmed by work and personal stressors. Reports cravings and difficulty abstaining from substances. **Review of Systems** Patient reports no new physical symptoms. Reports feeling anxious and irritable. **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: constricted 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