Presents in the office for medication management

Reference no: EM133704732

Question

Patient is a 42 year old AAM who presents in the office for medication management. Unfortunately he reports he is still using crack cocaine, heroin and smokes marijuana. His last use was yesterday. He reports he primarily abuse drugs to get high. In the office, he appears drowsy and sleepy and had to be prompted to wake up.He is oriented x4.Of note, client missed his last visit and he is out of medication.He reports ongoing struggle with his sleep. He was offered to be dropped at a turk house but he declined.He stated he has stuff to take care of before checking in, in a turk house and that he has an appointment with his PCP next week.Reports improvement in mood, sleep and appetite. Support and psychoeducation was provided. Constitutional Review of Symptoms: There is no recent history of weight loss, fever, malaise, or other abnormal constitutional symptoms.

Reference no: EM133704732

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