CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: “Things in my life have deteriorated so completely. I keep having these memories. I’m terrified because of what I did today. I’m really fucked up.”

Patient reports that today she went into her bathroom, took a razor blade, and made approximately twenty superficial lacerations to her thigh because “I had to let the pain out.” She denies any suicidal ideation, plan, or intent, and also any history of homicidal intent. No prior history of self-mutilation or suicide attempts, but she does admit that cutting self is “something I’ve thought about for a long time.” Patient reluctantly admits that trigger of current episode involves jealousy of her ex-girlfriend who is now dating her roommate. Pt cannot guarantee that she would remain safe at home without hospitalization .

PRESENTATION/MENTAL STATUS EXAM: Patient is a somewhat formally dressed, neatly groomed white female appearing her stated age. Alert and oriented. Speech was of normal rate and rhythm, somewhat theatrical, consistent with her flamboyant manner of dress. No noted neologisms or thought disorder, on the contrary patient was extremely coherent. At several points during the evaluation she became tearful. Claims that mood has been “incredibly tempestuous” but that lately her low periods have become more low. Patient does not appear to respond to hallucinations. At one point when the noise in the waiting area became loud client startled markedly. She states that this happens regularly.

PSYCHIATRIC HISTORY: Patient has no history of treatment.

Patient endorses current change in mood, depressed feelings, inability to enjoy usual activities, poor sleep with nightmares, poor concentration, increased anger and irritability. No evidence of mania, psychomotor agitation, or grandiosity. “I’m a horrible writer,” she states. She endorses similar episodes of depression at ages 9, 12, 13, and 20. No evidence of manic episodes.

Patient does endorse having frequent nightmares of sexual assault occurring to her at a carnival, and states that lately “these memories have been coming back and I’m not sure if they’re really real.” Ct is unsure if she was really raped as a child. She does claim to have trouble trusting individuals, and to feel hypervigilant while in public. She denies having flashbacks but does admit to having dissociative periods where she will find herself walking around, unsure of where she is. She states that the dissociation has happened “almost all my life” but claims that the other PTSD symptoms are new, having occurred in the past four months.

Ms. Schecter denies having auditory or visual hallucinations, thoughts of thought broadcasting, imposters, paranoia, persecution, or delusions of reference. No evidence of delusions of any kind, at present or in the past.

Patient admits to occasional marijuana use, last use two weeks ago, and even rarer use of hallucinogens, last use was approx eight months ago. “I’ll have like one beer every other day,” she states. No hx of other drug use.

Ms. Schecter’s friend reports feeling concerned about her dancing at “this really skeevy strip club”, and states that she feels the patient is putting herself in sexually exploitative situations in which she could become harmed. She states that when she expressed her alarm to patient, pt stated that she found it liberating because “it’s my choice.” She states that she had no idea patient was troubled enough to harm herself.

PSYCHOSOCIAL HISTORY: Patient is an only child of middle-class Jewish parents who divorced when she was thirteen. She reports that she excelled in school and went on to get a B.A. in English Literature and a MFA in Creative Writing. She currently works as a waitress and, per her friend, as an exotic dancer. Despite some success at fiction writing, she has been unpublished for the last several years.

Patient states that she identified as heterosexual until about one year ago, when she was seduced by an older woman. “My whole life fell apart,” she states. When her fiance learned of her infidelity he pressured her to get married, but shortly after that the relationship fell apart. She reports that she broke up with her most recent girlfriend because it was clear she wanted to be with another woman, patient’s roommate and best friend, who accompanies her to the evaluation. She reports that last night she heard the two having sex in the next room, but denies that this precipitated her episode of cutting.

Patient denies history of abuse, except for a rape that occurred at age ten, about which she is unsure, and a recent situation with a male roommate who was filming her and her female roommate, unknown to them. She does admit that this has a great deal to do with her increasing memories of possible rape: "I feel fucking violated."

DIAGNOSIS:

I: Post-Traumatic Stress Disorder, Delayed Onset
II: Deferred
III: Heart murmur, lacerations of L thigh.
IV: Financial stressors, Underemployment, Employment in a setting that evokes traumatic memories, dissolution of recent break up.
V: 32

TREATMENT RECOMMENDATIONS:

1. Due to lack of current treatment and patient’s inability to guarantee safety, will admit to Adult Locked Inpatient Unit, voluntarily, with constant observation for first 24 hours.
2. Start Zoloft 50 mg QD for three days, then increase to 50 mg BID.
3. Serum pregnancy, UDS, LFT, TSH, CBC and diff, electrolyte panel.

Marva Frank-Dunn, M.D.
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