NR 326-Mental Health Plan Assessment and Clinical Facility Patient Assignment.

NR 326-Mental Health Plan Assessment and Clinical Facility Patient Assignment. HPI (History of Present Illness): This client is from the Washington D.C. school system. In school, he reportedly had a history of acting out, defiant behaviour, bulling, and destruction of school property. In 2015, he threw a rock at a teacher, hitting her in the head. At this point DR was referred to Devereux, FL. It was stated that he made significant progress during this period. However, upon his return home, a sexual allegation was made against DR. The court found him incompetent, but was returned to Devereux GA, to, in the judge’s words, “achieve competency. At this point, his court case is still pending. His stay at Devereux is scheduled to end on 12/31/17. DR has stated the he will be “hurt” if he doesn’t return to the streets in Washington DC Past psychiatric history (include inpatient and outpatient): As mentioned, DR was in residential treatment in Devereux FL. His previous diagnoses from the Washington DC school board included: Depressive anxiety, mood disorder, mixed expressive receptive disorder, and borderline intellectual disability. His current stay in Devereux GA, is court supported, mentioned above. His current diagnoses are somewhat different, including: Oppositional defiant disorder, ADHD, and moderate intellectual disability. DR has had mental health services beginning at five years old Family Psychiatric History: DR’s family history has a paternal gap, and no maternal issues are listed in the charts. DR has a maternal cousin in prison Social History / Psychosocial Assessment: DR lives in a three person household, including his mother, and grandmother. He has no listed siblings; the chart states his mother is unemployed. His family is not religious, and doesn’t appear to be involved in any community services. Staff states DR is friendly, outgoing, and makes Tobacco use? NO Illicit Drug use? YES Frequency/amount: claimed about once every six weeks Alcohol use? YES Frequency/amount: claimed about once every six weeks CAGE Questionnaire, if applicable: N/A Item YE S N O Have you ever felt you should cut down on your drinking? 1 0 Have people annoyed you by criticizing your drinking? 1 0 Have you ever felt bad or guilty about your drinking? 1 0 Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)? 1 0 TOTAL SCORE Physical Assessment: Vital Signs: Time: 10/04/17 Temp: 98.0 F Pulse: 59 BP: 108/80 Resp Rate: 16 O2 sat: 98% O2 delivery: N/A (room air) Pain: 0 Pain reassessment: N/A reassessment time: N/A Physical Assessment Documentation Integumentary Respiratory HEENT GI/GU Cardiac Musculoskeletal Neuro Sleep Patterns: DR has no specific documentation on the above. Visually, he appears within normal limits, displaying no obvious physical difficulties during a physical education activity. He was oriented to place, person, and situation, and spoke at an appropriate developmental level, in terms of vocabulary and speech pattern.