Master Treatment Plan

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Name: James E. Roberts
Course: CMSW 1313
Date: 11/24/10

Master Treatment Plan

Person’s Name: Edward Kojak

Date of first visit: 10/15/10

I. Identified Problems:

Primary Problem: Bipolar II disorder
Secondary Problem: Poly-substance in remission
Tertiary Problem: unemployed

II. Historical Data:

Primary Problem: Bipolar II disorder

Symptoms and/or history: : Client stated he began SDTP in 2004 and spent 9 wks on an inpatient psychiatric unit while incarcerated following an episode in which he "bottomed out" following an episode of Stephens-Johnson syndrome while on tegretol in 4/08. Described "bottomed out" to be increased isolation, hypersomnia, and nightmares.

Client cited current symptoms of A/VH, nightmares, isolation, hypersomnia. Reported approximately every 7-10 days he will go through a depressive episode characterized by suppressed appetite and decreased hygiene. Client also reported instances in which the AH will become so loud and overwhelming he becomes "agitated", most recently occurred on the bus last week. Suicide attempts in the past year: None

Psychiatric hospitalization in Texas Department of Criminal Justice from 12/08-2/09 for evaluation and treatment of mood disorder (bipolar1) Treated as an outpatient for major depression in SDTP in 2005. Currently treated for bipolar disorder at MHMRA.

Secondary Problem: Poly-substance in remission?)

SUBSTANCE ABUSE/DEPENDENCE HISTORY: Substances used
Alcohol: last drink was 08/05. Client approximated date of last use. Client reported having abused tequila most often. Also reported abusing valium and Boone’s farm while in the military following a back injury. Opiates: last used on 08/22/05. Client reported having last used opiates on the above date when he attempted to hurt himself by overdosing on lortabs and other pills. Cocaine; last used on 08/05. Client approximated date of last use. Client reported having used crack cocaine & powder cocaine. Amphetamines;...
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