Comprehensive Psychiatric Evaluation
Comprehensive Psychiatric Evaluation Template
Subjective
CC (chief complaint): I need help stopping my use of opioids and alcohol so that I can get clean and start treatment for hepatitis C.
HPI: Lisa Tremblay is a 33-year-old woman who is in the detox center in Naples, Florida and is considering long-term rehabilitation. Daily opioid use reports around 100 a day, drinking 1/2 gallon of vodka a day, and cannabis use 1-2 times a week with a medical card. She claims to sleep five to six hours a night and has lost her appetite, preferring to get high instead of eating. She has a history of drug paraphernalia possession with one arrest. Admission labs reveal high ALT 168, AST 200, ALK 250, bilirubin 2.5, albumin 3.0, GGT 59, and a blood alcohol screen of 0.308 and a urine drug screen positive for opiates and THC. She indicates childhood sexual abuse by her father, and is no longer in contact with him, and has a family history of substance abuse.
Past Psychiatric History
• General Statement: The patient has a history of substance use, such as opioids, alcohol, and cannabis, and a history of being sexually abused as a child between 6 and nine years old.
• Caregivers (if applicable): Not applicable.
• Hospitalizations: No prior psychiatric hospitalizations are reported
• Medication trials: No psychiatric medication trials are reported.
• Psychotherapy or Previous Psychiatric Diagnosis: No history of psychotherapy or previous psychiatric diagnosis is reported.
Substance Current Use and History: The patient reports daily opioid use costing approximately one hundred dollars, daily alcohol use of one half gallon of vodka, and cannabis use one to two times weekly with a medical card.
Family Psychiatric/Substance Use History: Mother has a history of agoraphobia and benzodiazepine abuse, and she resides in Maine. Older brother had a history of opioid abuse and has been out of touch with the family for the last ten years. Father is known to have drug charges and has been incarcerated.
Psychosocial History: The patient claims that she experienced sexual abuse in childhood between the ages of six and nine by her father and is not in touch with him at the moment. She is in a detox center in Naples, Florida, and she is planning long-term rehab. She mentions that she sleeps five to six hours a night, has a loss of appetite, and prefers to get high rather than eat.
Medical History
• Current Medications: No current medications are reported.
• Allergies: Azithromycin
• Reproductive Hx: Not reported
ROS
• GENERAL:Reports decreased appetite and sleeping five to six hours per night.
• HEENT:Denies changes in vision, hearing, or headaches.
• SKIN:Skin intact with no reported rashes or lesions.
• CARDIOVASCULAR: Denies chest pain or palpitations.
• RESPIRATORY: Denies shortness of breath or difficulty breathing.
• GASTROINTESTINAL: Reports decreased appetite, denies nausea or vomiting.
• GENITOURINARY: Denies urinary symptoms or changes.
• NEUROLOGICAL: Denies seizures, dizziness, or loss of consciousness.
• MUSCULOSKELETAL: Denies muscle pain or joint stiffness.
• HEMATOLOGIC: Denies bleeding or bruising tendencies.
• LYMPHATICS:No lymph node swelling reported.
• ENDOCRINOLOGIC: Denies intolerance to heat or cold.
Vitals
• Temperature: 100.0°F
• Pulse: 108 bpm
• Respirations: 20/min
• Blood Pressure: 180/110
• Height: 5’6”
• Weight: 146 lbs
Physical Exam
• General Appearance:The patient appears her stated age with appropriate grooming and hygiene. She is alert, oriented, and engages in the evaluation.
• HEENT: Head is atraumatic with normal facial symmetry and no visible abnormalities of the eyes, ears, nose, or throat.
• Cardiovascular: Heart rate is elevated at 108 beats per minute and blood pressure is 180 over 110.
• Pulmonary: Respirations are 20 per minute with no signs of distress.
• Gastrointestinal: Abdomen is soft with no signs of discomfort.
• Genitourinary: External structures appear normal.
• Musculoskeletal: Muscle tone and movement appear intact.
• Neurological: The patient is alert and fully oriented.
• Endocrine: No visible signs of glandular enlargement.
• Psychiatric: The patient is alert and oriented and engages in treatment. She reports ongoing opioid, alcohol, and cannabis use, with decreased appetite and sleep disturbance.
Diagnostic results: Admission laboratory results reveal ALT 168, AST 200 and ALK 250. Bilirubin is 2.5, albumin is 3.0, and GGT is 59. Urine drug screen is positive for opiates and THC. Blood alcohol level is 0.308, and positive for alcohol or other drugs. Other laboratory values are normal.
Assessment
Mental Status Examination: Lisa Tremblay is a 33 year old woman who looks her age and is well dressed. She is compliant and engages in the assessment. Her behavior is restrained, and no unusual movements are noted. Speech is clear, coherent, and normal in rate and tone. Her mood is reflective of her current situation, and her affect is appropriate. Thought processes are rational and objective oriented. Thought content revolves around substance use and willingness to become clean before beginning hepatitis C treatment. She denies the presence of hallucinations and other disturbances of perception; no delusional thinking is present. Denies suicidal or homicidal ideation. Cognitively, she is alert and oriented. Insight is present, and judgment is impaired as evidenced by continued substance use.
Differential Diagnoses
1. Alcohol Use Disorder, severe (ICD 10 F10.20)
This is the main diagnosis because the patient reported having been drinking one-half gallon of vodka per day, and she had a blood alcohol level of 0.308 at admission (Miller et al., 2023). Laboratory results such as ALT 168, AST 200, ALK 250, bilirubin 2.5, albumin 3.0, and GGT 59 reflect extensive liver involvement. DSM 5 TR criteria were met, such as persistent use, use in large amounts, and continued use despite physical harm, and impairment in functioning, as seen in loss of appetite and prioritizing substance use above eating. The Pertinentpositives are heavy daily alcohol consumption, abnormal lab results, and sleep disturbance. Pertinent negatives are the lack of hallucinations, delusions, and suicidal or homicidal thoughts.
2. Opioid Use Disorder, severe (ICD 10 F11.20)
The patient claims to take opiates daily and to spend about one hundred dollars on them, and the urine drug screen has tested positive for opiates (Lee et al., 2024). Supported DSM 5 TR criteria include continued use despite consequences and persistent use despite consequences, such as a history of drug paraphernalia possession and one arrest. Pertinent positives are chronic daily use and positive toxicology. Pertinent negatives are that no opioid related psychotic symptoms have been reported. This diagnosis is a secondary diagnosis to alcohol use because it has less immediate physiological risk than alcohol intoxication and liver dysfunction.
3. Posttraumatic Stress Disorder (ICD 10 F43.10)
This is taken into consideration, considering that the patient reported being sexually abused by her father since the age of six and nine, and she is estranged (Shalev et al., 2024). Nevertheless, DSM 5 TR criteria are not entirely achieved since there are no reported instances of reexperiencing, avoidance, and hyperarousal symptoms. Pertinent positives are trauma history. Pertinent negatives are the absence of trauma-related symptoms reporting.
Critical Thinking Process:The main diagnosis of Alcohol Use Disorder, severe (ICD 10 F10.20) was chosen because of the daily heavy alcohol consumption, the BAL of 0.308, abnormal liver laboratory, and evident functional impairment in sleep and nutrition (Miller et al., 2023)..
Reflections: Given a chance to redo this session, I would use a more comprehensive, trauma-informed, and medical approach. Although the patient was insightful and motivated to change, I would further evaluate the withdrawal risk severity by collecting the history of seizures, delirium tremens, overdoses, and previous treatment results. Since she has high vital signs and severe liver abnormalities, it would be necessary to focus more on medical stabilization and detox planning. Also, I would look deeper into her trauma history and examine her PTSD symptoms, depression, and coping strategies because they are likely the root cause of her substance use (Shalev et al., 2024). An integrated approach that incorporates her wish to receive hepatitis C treatment into a coordinated care plan earlier would also reinforce motivation and continuity of care.
Legally and ethically, this case goes beyond confidentiality and consent (Shelat, 2025). Her degree of intoxication and medical unsteadiness makes it a matter of concern in terms of decision-making capacity, and therefore, the informed consent is to be timely and documented. It is also ethically necessary to avoid harm by observing in case of life-threatening withdrawal and liver disease complications. Her childhood abuse history means she needs to be aware of laws on reporting and understand that the previous abuse might not trigger reporting unless there is a current risk. Also, it is important to prevent stigma associated with substance use and criminal record to maintain the principle of justice and fair treatment, which means that she will receive equal access to treatment services, such as rehabilitation and hepatitis C treatment.
The health promotion and disease prevention must be personalized to her risks. With a history of polysubstance use at 33 years old and liver impairment, the priority should be overdose prevention with naloxone, hepatitis A and B vaccination, nutrition, and education about safer substance use practices in case of relapse (Pridgen et al., 2025). Her history of trauma, substance use in the family, and possible socioeconomic instability can influence adherence, and it is essential to connect her to long-term rehabilitation, mental health therapy, and social support services. Discussing sleep, nutrition, and coping strategies will further promote recovery and decrease disease progression.
References
Lee, Y. K., Gold, M. S., Blum, K., Thanos, P. K., Hanna, C., & Fuehrlein, B. S. (2024). Opioid use disorder: current trends and potential treatments. Frontiers in Public Health, 11, 1274719. https://doi.org/10.3389/fpubh.2023.1274719
Miller, A. P., Kuo, S. I., Johnson, E. C., Tillman, R., Brislin, S. J., Dick, D. M., Kamarajan, C., Kinreich, S., Kramer, J., McCutcheon, V. V., Plawecki, M. H., Porjesz, B., Schuckit, M. A., Salvatore, J. E., Edenberg, H. J., Bucholz, K. K., Meyers, J. L., Agrawal, A., Alcoholism, C. S. O. T. G. O., . . . Parsian, A. (2023). Diagnostic criteria for identifying individuals at high risk of progression from mild or moderate to severe alcohol use disorder. JAMA Network Open, 6(10), e2337192. https://doi.org/10.1001/jamanetworkopen.2023.37192
Pridgen, B. E., Bontemps, A. P., Lloyd, A. R., Wagner, W. P., Kay, E. S., Eaton, E. F., & Cropsey, K. L. (2025). U.S. substance use harm reduction efforts: a review of the current state of policy, policy barriers, and recommendations. Harm Reduction Journal, 22(1), 101. https://doi.org/10.1186/s12954-025-01238-4
Shalev, A., Cho, D., & Marmar, C. R. (2024). Neurobiology and treatment of posttraumatic stress Disorder. American Journal of Psychiatry, 181(8), 705–719. https://doi.org/10.1176/appi.ajp.20240536
Shelat, V. G. (2025). Respecting privacy and upholding confidentiality: core ethical duties. Singapore Medical Journal, 66(12), 685–689. https://doi.org/10.4103/singaporemedj.smj-2025-147