CC (chief complaint): So, I have a history of taking medications and then stopping
them. I don't think I need them. I really feel like the medication squashes who I am.
HPI: The patient is a 27-year-old White woman reporting to the clinic for a psychiatric
evaluation after she faced a challenge with medication compliance. She states that she stops
taking medication sometimes when she feels better. She reports that when she was a teenager, her
mom put her in the hospital after she went four days without sleeping. She also reports hearing
voices at that time and was started on some medication she is unsure about. She reports four
previous hospitalizations, one of which was linked to a suicidal attempt. She reports
experiencing episodes when she does not want to go to bed about four times a year. Other
symptoms include lack of motivation to do anything, low energy, lack of interest in her
creativity, and feeling like she is not worth anything because she feels her creativity Is slipping
away. She indicates that her symptoms often last for about five days, followed by immediate
episodes of depression. She also reports an increased appetite when she is not doing her art. She
denies bad dreams and has five to six hours of sleep.
Substance Current Use:
The patient admits to smoking a pack of cigarettes a day and is not going to quit it for the
therapist. She also reports that she stopped taking alcohol when she was 19 because they didn’t
go together. However, she denies taking marijuana and other illicit substances, including cocaine,
stimulants or methamphetamines, huffing or inhalants, Klonopin or Xanax, any of those sedative
medications, hallucinogenic like LSD, or PCP, or mushrooms, pain pills or opiate medications, or
anything synthetic like Spice, or ecstasy, Bath Salts, Mollies. She denies seizures from alcohol or
drug use.
Family History
The patient reports that her mother was seen as crazy. She suspects that she has bipolar or
something. She unsuccessfully attempted suicide. Her father was arrested and went to prison for
drugs, and they have not heard from him in 8 or 10 years. She also reports that her brother was a
little schizophrenic but has no history of diagnosis or doctor’s evaluation.
Medical History:
The patent reports that she has hyperthyroidism that is currently being managed by medication.
she also reports taking birth control pills for polycystic ovaries.
Current Medications:
The client reports taking Zoloft for her depression but indicates experiencing side effects,
including feeling really high, difficulty sleeping, and racing thoughts. Additionally, she
was prescribed risperidone and Seroquel, that caused unintentional weight gain. Finally,
she took Klonopin, which seemed to slow her down. She reports stopping taking these
medications at some point.
Allergies: She denies any NKDA, food, environmental, animal, or seasonal allergies.
Reproductive Hx:
She is currently sexually active with multiple sexual partners since she reports having
casual sex to make her feel better. She denies any history of pregnancies and has regular
menses, with her LMP being about a month ago. Even though she does claim that she is
safe, she does not report any history of STIs or tests for the same.
Social History
The patient reports that she was raised by her mom and lived with her and her brother. However,
she also lives with her boyfriend but sometimes returns to her mother’s when they have issues
about her sleeping around. She has never been married and works part-time at her aunt’s
bookstore. However, she has been missing some work days when she is depressed. She is in vo-
tech school right now for cosmetology and is going to do makeup for movie stars. Her fun time
activities include writing her life story, which she intends to publish, and painting.
ROS:
General: He is hyperactive and strong. He reports recent weight gain and has been eating
a lot. He denies chills or fever.
HEENT: He reports recent head trauma when playing hockey and once during a fight.
Eyes: He is not wearing contacts and denies vision problems such as double or blurred
vision or yellow sclerae. Ears, Nose, and Throat: He denies hearing problems, ear pain, or
discharge. He also denies sinus pain, nasal congestion, sneezing, runny nose, or sore
throat.
Skin: He denies skin itching or rashes
Respiratory: He does not report any history of
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