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Mr Cook Case Summary

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Mr. Cook is a 30 year old male who presented to the ED with substance abuse issues with Suboxone and "downer". He reports a history of bipolar. Per documentation family brought him in becaue they do not feel safe with him living in their home. Dr. Gentry requested a consult with mental health to determine appropriate services. He denies suicidal ideation, homicidal ideation, and symptoms of psychosis to ED staff. At the time of the assessment Mr. Cook continues to denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He acknowledges a history of polysubstance abuse. He reports last inpatient treatment was at Moore Regional Hospital. He agreed for his records from Moore Regional to be released to Randolph Health. Per documentation Mr. Cook was sent to Moore Regional Hospital from Randolph Hospital 10/13/15 and was treated for substance abuse services. At there facility he diagnosed with Opiate Dependence, Major Depression, Recurrent Episode, Moderate; personality disorder not otherwise specified with borderline and narcissistic histrionic features. He was encouraged upon discharged to follow up with Sober Living America or Daymark, which did not happen afterwards. Mr. Cook stated at that time suicidal ideation and auditory hallucinations, however symptoms were resolved and his primary concern was to "get off medication. He has a …show more content…
Cook most recent UDS he tested positive for cocaine,marijuana, methadone, opiates, and benzodiapines. He admits to using .9 mg of Heroin 6/13/17. He reports smoking a "joint" yesterday as well. During the assessment Mr. Cook ask several time about getting into a substance abuse facility who prescribe Methadone. He was confronted about wanting Methadone when in 2012 having issues with the medication and addictive behaviors. He states, "I need something, you know, I'm hurting." He reports withdrawal symptoms as diarrhea, cold sweats, and tremors. He expressed agitation over the course of the past few

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