Substance Abuse Case Study Sample

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. IDENTIFYING DATA: The patient is a 29 year old AA male currently serving 25 year setence for COCAINE-SALE/MANUF/DELIV (X6) COCAINES POSSESSIONN (X6) GUN/W/DEADLY/WPN (x3). He entered FLDOC 4/7/2010 TRD:10/03/2033. This is his first prison term in the state of Florida. II. REASON FOR ADMISSION: Transferring SYSM: The patient referred to MHTF due He presented of three episode of self-injury behavior within 2 Weeks. IM has been in and out SHOS for cutting self and have had the extraction the team. III. RELEVANT MEDICAL AND MENTAL HEALTH HISTORY: Per records, . Medical Hx: see inpatient chart. Substance Abuse Hx: Per record review COCAINE possession. No history of substance abuse treatment. Per OBIS IM has not been identified as a mandatory participate in substance abuse treatment. Past psychiatric Hx: Records indicate that the patient has had a history of first outpatient at the age of 8, and has been Baked Act many times for suicidal attemptst. Hx of MH Tx in DOC: During this incarceration IM has received inpatient and outpatient treatment for self-harm, depression, and suicidal threats. He has an extensive history of inpatient admissions including MHTF. IV. ADMISSION MENTAL STATUS EXAMINATION & PROVISIONAL ADMISSION DIAGNOSIS: DSM-5: The patient has been diagnosed with (F32.0) Unspecified Depreesive D/O ,…show more content…
CURRENT MENTAL STATUS EXAM: The patient was evaluated on 7/11/17 by MHP. On that day, the patient is O X 3 (oriented times three; oriented to person, place, and time). His thinking is clear and linear. Memory appears adequate. Affect/mood is somewhat congruent, he wore standard prison attire, eye contact and hygiene were appropriate, and he was cooperative with the interview. His speech was typical in rate, tone, and clear. Thought process was coherent, no difficulty with attention or concentration. He denied suicidal and homicidal ideation with no intent or plan. He reports eating 3/3 of the meals & achieving 7-8 hours of sleep per
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