Substance Current Use: The patient denies substance/ illicit drug current use.
Substance Use History: Previous marijuana (cannabis) use.
Previous Psychiatric Hospitalization: The patient reported one-time psychiatric hospitalization.
Family Psychiatric History/Substance Use: The patient reports autism (son) and denies family suicide attempts and substance use.
Medical History: seizure disorder, hypothyroidism.
Current Medications: paroxetine (paxil) 30mg p.o daily (depression), buspirone 10mg p.o tid ( anxiety), prazosin 1mg nightly (nightmares), 750 mg deparkote p.o daily (seizures / mood stabilization), Synthroid 50mcg p.o daily (hypothyroidism).
Medication Trial: Abilify 5mg p.o daily, risperidone 2mg p.o.daily.
Psychotherapy or Previous Psychiatric Diagnosis: The patient is non-compliance with individual psychotherapy. Previous psychiatric diagnoses include post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder.
Allergies: medication reaction, Abilify ( causes seizures per patient), risperidone (causes rashes).
Reproductive Hx: heterosexual (sexually active), denies pregnancy and lactation.
Social History: The patient was raised in Maryland by her mother. She is single, unemployed, and lives in Maryland with her nine-year-old autistic son. She has one elder sister. Her highest level of education is a high school diploma. She reported childhood sexual and emotional abuse and multiple legal histories.
ROS:
GENERAL: patient appears anxious, with no complaints of weight loss.
HEENT: No complaints of visual loss or double vision. Ears, Nose, Throat: No complaints of hearing loss, sneezing, congestion, and sore throat.
SKIN: No complaints of rashes or itching on the skin.
CARDIOVASCULAR: No complain of chest pain, and palpitations.
RESPIRATORY: No complaints of shortness of breath and cough.
GASTROINTESTINAL: Patient reported feeling a little nauseous.
GENITOURINARY: No complaints of burning on urination or urgency.
NEUROLOGICAL: The patient reports slight headache, but denied syncope and recent seizures.
MUSCULOSKELETAL: No complaints of muscle pain, and joint pain.
HEMATOLOGIC: Denies complaint of anemia, and bruising.
LYMPHATICS: No complaints of enlarged nodes.
ENDOCRINOLOGIC: The patient denies sweating, cold, polyuria, or polydipsia.
Objective:
Diagnostic results: Review of patient’s labs revealed.,
Urine Drug Screening (UDS): Normal.
Comprehensive metabolic panel (CMP): Normal.
Complete Bood Count (CBC): Normal
Liver Function Test: Normal.
Thyroid Function Test: Normal.
Ammonia Level: Normal. Performed to assess the possibility of hepatic encephalopathy.
Alcohol Level: Normal.
Deparkote (Valproic acid) Level: 20mcg/ml. This indicates medication noncompliance.
Pregnancy Test: Negative.