New Patient Note

**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