You are on page 1of 4

6/22 tsh 1.210, 0.450-4.

5 rpr non reactive 5/21 chest xray one view, clinical indication: annual exam: no acute intrathoracic disease, mild left basiliar atelecstasis 5/20 hep a Ab, igm - neg HBsAg screen - neg Hep b core Ab, IgM - neg Hep C Virus Ab - <0.1, 0.0-0.09 Wbc 7.2, 4-10.5 Rbc 4.97, 4.1-5.6 Hbg 15.3, 12.5-17 Hct 45.1, 36-50 Plt 254, 140-415 Ney 63, 40-74 Lym 29, 14-46 Mon 6, 4-13 Eos 2, 0-7 Bas 0, 0-3 6/9 Glucose 88, 65-99 6/17 Cholesterol 151, 100-199 Triglycerides, 105, 0-149 Hdl, 55, >39 Vldl, 21, 5-40 Ldl 75, 0-99

6/22 glucose 89 BUN 11, 5-26 Creatinine 1.3, 0.76-1.27 eGFR >59, >59 bun/crea ratio 8, 8-27 sodium 138, 135-145 potassium 3.9, 3.5-5.2 chloride 99, 97-108 co2 22, 20-32 calcium 9.5, 8.7-10.2 protein 6.9, 6.0-8.5 albumin 4.5, 3.5-5.5 globulin 2.4, 1.5-4.5 a/g ratio 1.9, 1.1-2.5 bilirubin 0.5, 0-1.2 alk phos 56, 25-150 ast 34, 0-40 alt 44, 0-55

8/1/11 gluc 79 chol 141 trig 85 hdl 56 vldl 17 hdl 2.5

ldl 68

vs 9/24/11 - 98.8 78 16 114/80 225 lbs 9/17 98.2 77 20 112/72 230 lbs 9/16 98.2 69 20 118/67 225 lbs

Abilify 15 mg QD Trilafon 16 mg HS Cogentin 0.5 mg BID Fenobitrate 160 mg QD Niacin 500 mg QD Toprol XL (Metoprolol Succinate) 25 mg QD Zocor 40 mg HS

Able to read & write, 12th grade GED, denies future educational goals, average grades, suspended frequently from school, skipped classes, likes outdoor activities, heterosexual, denies past intimate relationships, never had romantic involvement, worked as store clerk at cafeteria, Alcohol since 15 yr old, twice month, 20 yrs, 2006 last use Cocaine client denies past use Marijuana denies past use, although he has tested positive in the past Hx of paranoid ideations, hallucinations, delusions, drug abuse

Allergies to prolixin and mango Height 510

Has been on conditional release and placed at bayview. Did not attend his treatment program and later tested positive for marijuana and cocaine. Denied ingestion of

any substances, saying he was bitten by snakes causing him to test positive, was adjudicated as incompetent based upon the evaluators reports and remanded to facility as civil commitment under mosher vs state as he was deemed as nonrestorable. Poor historian, history he provides may not be wholly factual. Demonstates a great deal of denial regarding any post difficulties of substance abuse, mental healthm or abuse nature. He claims good childhood experiences, no physical emotional or sexual abuse. During another interview, he reported that someone named wayne abused him physically. At one time someone put something in his drink and did something to him, although he refused to address the issue. Never married, no children, never dated or had girlfriend. Reported using alcohol at age 12. School history conflicts, he says homeschooled and went to Miami Edision High School. He claimed to received As during all school years.

Dr deemed him incompetent, presents with bizarre ideations, disorganized thinking, delusions, grandiose beliefs. Speaks of drugs being the air and reported to be responding to internal stimuli by treatment staff at baview. Displayed paranoid thinking about people spitting and putting things in his food. Laughed inappropriately, responded to hallucinations, otherwise quite bizarre. Never arrested prior to 2005. Aggravated stalking charge, followed a woman and told her I am going to prison. You better watch out. I am going to rape you. The next time be careful. I am going to rape you. Police patted him down and found a 6 steak knife.

States he is homeless but has worked all his life and is retired. Claims to be inventor of shampoos and too many others thing to mention. Admits use of nicotine and alcohol but denies drug use. Cooperative, calm, quiet as well as appropriate with staff, no insight with respect to relationship between substance abuse and mental illness. Notes to laugh to himself and appears to respond to internal stimuli. exhibits good boundaries, polite, cooperative, thinking is deemed to be logical, speech is disorganized at times. Demonstrates childlike attitude and claims everything is all right. Clean appropriately attired, mood appeared depressed with flat affect, poor mathematical reasoning, fairly good abstract reasoning, reasonable practical judgment, no significant memory deficits, denies depression, no sleep or appetite disturbances, long hx of psychiatric symptoms and hospitalization,