Substance Current Use: The patient denies substance/ illicit drug current use.

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.


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.


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.

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