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The Episode: Interlude

Composed on the 26th of July in the year 2011, at 8:40 AM. It was Tuesday.

PATIENT’S NAME: WELCH, PETER H.

SEX: M.

ADMIT DATE: 8/24/2000.

HANDEDNESS: He is ambidextrous.1[1]

ALLERGIES: Allergies to dust, pollen, cats, and dogs.

PAST MEDICAL HISTORY: He denies any recent exposure to infectious process, but states that he was exposed to HIV when he was 18 years old. He states that a friend of his was cutting himself, that he wanted his friend to stop cutting himself, and that he licked his friend’s blood.2[2] When asked if this person had HIV, he said he thought so.3[3] He has a history of a head injury. He states he was dropped when he was little.4[4] He tripped and fell onto a concrete floor at the age of 4 and lost consciousness.5[5] He is unable to give me any other medical history.

PAST PSYCHIATRIC HISTORY: According to the patient’s mother, when he was 6 years old, he had a psychiatric evaluation due to depression and anxiety. He participated in family therapy and improved. As a teenager, mother remembers him as having been on and off depressed but never to the point of requiring treatment.

SURGERIES: Tonsillectomy at age 7, appendectomy at age 8.6[6]

FAMILY HISTORY: He is unable to me his mother’s or father’s ages. When asked how old they were, he told me 150. According to him they are both alive and well, but he has a brother age 25, a brother age 21, and a sister age 21 with no health problems.7[7],8[8],9[9]

SOCIAL HISTORY: He has been living at 16 Maple Street in Bar Harbor. He attended MDI High School, but left after his sophomore year. He has worked as a waiter, dishwasher, tennis instructor, and a bartender.10[10] He states he also has taught math and English.11[11]

CONDITION AT ADMISSION: Upon admission, Peter presented as a disheveled, withdrawn, guarded, and underweight young Caucasian male.12[12] He had very poor eye contact, minimal cooperation with the interview. There was significant psychomotor retardation to the point of near catatonia.13[13] For prolonged periods of time during the interview, he would remain almost motionless with closed eyes. When moving, he would do it extremely slowly. His speech was spontaneous,14[14] fluent, hypophonic,15[15] and monotone, without much inflection and minimal emotional content. His mood was detached, and affect flat. Though processes were with significant circumstantiality, tangentiality, and loosening of of associations. At times, he was positive for thought blocking.16[16] His thought content was with vague delusions of persecution. He had positive visual and auditory hallucinations.17[17] He denied in an inconsistent manner suicidal and homicidal thoughts or plans. His cognition was difficult to assess because of poor compliance. He appeared alert and orientated to person and place, but not to time. When asked the date, he initially replied February 28, 1980,18[18] and then later on, January 1, 2000.19[19] Capacity to focus, sustain and shift attention, as well as the ability to present the events of recent days in a sequential manner, were severely impaired. His insight and judgement were quite poor.20[20]

IDENTIFYING INFORMATION: Peter Hunt Welch is a 20-year-old single Caucasian male who was residing in Bar Harbor, Maine this summer. He is a University of Maine at Orono student with no prior psychiatric history, who was admitted to the Acadia Hospital on an involuntary basis21[21],22[22] due to an acute level of confusion and disorganization, both behaviorally and cognitively. He was evaluated at MDI and was transferred from that facility due to psychosis, impulse thoughts, delusions, and disorientation. He was felt to be a risk to himself and others due to his high level of disorganization and disorientation and impulsivity.23[23] He did not know where he was. He believed that he had murdered his friend by sucking out his soul.24[24] The patient was also reporting, upon admission, that he could see, smell, hear and touch God, She has an acid smokey smell.25[25] Patient is an unreliable historian.26[26] He initially denied any alcohol or drug use, but later on admitted to having had LSD on several occasions.27[27] He also acknowledged the use of heroin, crack, cocaine, mushrooms, ecstasy, speed, etc.28[28],29[29],30[30] Just prior to his admission to Acadia Hospital, he had been displaying markedly abnormal behavior with confusion, illogical statements, and appearing disoriented, and as if walking in a daze. When asked about sexual activity, he does not discuss whether he prefers males or females, but states that he has used condoms,31[31] and he has been sexually active. He reported unusual experiences like having seen the earth and the bottom of the sea. He stated that almost continuously he is able to see around him many of his friends.32[32] He acknowledged the presence of thought broadcasting but denied thought insertion or withdrawal.33[33] He also denied any ideas of reference.34[34]

PHYSICAL EXAMINATION: General: This is a very emaciated, 20-year-old who is awakened for the physical. He is somewhat sedated. He is very spacey. He appears to be responding to internal stimuli and stares. No eye contact. He is cooperative. He was been making inappropriate hypersexual comments, so much of this physical examination is also limited, due to that fact.35[35] Height is 5 feet 8 inches.36[36] Weight is 123-1/4 pounds.37[37] Temperature is 37,38[38] pulse 60, respiration 16, blood pressure 108/80. Head: Normocephalic.39[39] No lesions or tenderness. Skin: There is some slight facial acne. Patient appears to have a tinea infection of his arms, back, and chest.40[40] Eyes: Pupils are equal, round, and reactive to light and accommodation.41[41]

NEUROLOGICAL EXAMINATION: The patient is not oriented to time, place, person, or situation. He appears to be responding to internal stimuli.42[42] He hesitates for several moments before being able to answer questions.43[43] He has trouble retrieving information.44[44] Cranial nerves I-XII are intact. Cranial Nerve I: The patient is able to detect peppermint.45[45]



DIAGNOSES:

AXIS I:

1. Psychosis, NOS (not otherwise specified).

2. Rule out substance-induced delirium, probably due to LSD (lysergic acid diethylamide).

3. Rule out substance-induced psychosis.

4. Rule out schizophrenia.

5. Rule out schizoaffective disorder.

6. LSD, heroin, cocaine, mushrooms, ecstasy, and amphetamine abuse.46[46]

AXIS II: Deferred.47[47]

AXIS III: Status post tonsillectomy; history of multiple sinus infections.

AXIS IV: Psychological stressors: Severe - Suicide of friend, recent relationship breakup, and family arguments.

AXIS V: Global Assessment of Functioning: Current: 15.48[48],49[49]



PLAN: Admit patient to 3-south. Monitor for psychosis and cognitive difficulties. Physical exam and labs. Start Risperdal 1.5 mg twice a day50[50] and Thorazine 100 mg q.i.d. p.r.n.51[51] to with agitation, irritability, and explosive behavior. Initiate a Valium protocol.52[52] Start multivitamins one q.d. and thiamine 100 mg q.d. Involve in the milieu. Obtain more information from family.



THIS REPORT IS STRICTLY CONFIDENTIAL.

Redisclosure is prohibited by law.



NOTE: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42CFR part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

PERMISSION REQUEST: I would like to ask myself if it’s okay to post my medical records on the internet to entertain total strangers in a public forum. I need explicit permission.

PERMISSION APPROVAL: Because of our tautological relationship, I hereby explicitly grant myself the right to post this information in whatever forum I please.

Next week

Meeting my new roommates.

1 Dextrous as I am, this is not technically true, though I may have said so. Hell, it may have been true at the time.

2 It was a liberal arts school.

3 He only mentioned the possibility after I licked the blood. Turns out he didn’t, and it turns out HIV can’t survive in open air, so even if he did, odds of transmission were dismal.

4 According to my parents. Go ahead, laugh it up.

5 I still remember this, but it may be a fake memory.

6 I must have told them this. The tonsils came out around 9, and I still have an appendix.

7 I don’t know where these siblings came from. I have one brother, who was 16 at the time. I also don’t know why there’s a “but” in that sentence.

8 Amy’s notes: They’re using “but” as “regardless.”

9 It still sounds stupid.

10 True, true, true, false.

11 Sort of.

12 They would have said this if I’d shown up sane, sober, and with a Ph.D. dissertation in my hands.

13 I thought I was dead, and dead people don’t move much.

14 Deferring to my friend Amy again for professional insight. Amy’s notes: Which, to me, contradicts observations that you were responding to internal stimuli before answering.

15 Amy’s notes: soft or weak voice.

16 Wikipedia says “Thought blocking, a phenomenon that occurs in people with psychiatric illnesses, occurs when a person’s speech is suddenly interrupted by silences that may last a few seconds to a minute or longer. Amy clarifies: It means you weren’t saying whatever popped into your head and seemed to be actively trying to push it away.

17 Not true, though I can understand why they thought so.

18 This has to due with a complicated delusion involving being reborn; that’s my actual date of birth.

19 Another delusion involving the restart of the universe on one of my generation’s original doomsday dates.

20 They nailed that one.

21 This, according to the insurance companies, wasn’t precisely true, since I signed myself in when I was initially admitted. My dad later pointed out to the insurance company, “When my son signed himself in, the only person he put on his visitors list was his dead ex-girlfriend. If you want to take this to court, let me know.” The insurance company didn’t call back.

22 Amy’s notes: And if you hadn’t signed yourself in, you probably wouldn’t have been hospitalized at all because it’s incredibly difficult to get someone involuntarily committed unless they’ve been seen multiple times in the same emergency department within a relatively short period of time and they have been very, very disruptive. Seriously—I’ve had clients threatening my life, destroying property and significantly injuring themselves get discharged from the ER back to me before the end of my shift.

23 Sometimes people still say this about me.

24 My means of killing Jake had evolved somewhat.

25 Prove me wrong.

26 Hah!

27 True.

28 False, false, false, true, false, true, etc.? Etcetera in a substance abuse report? Was I boring them?

29 Amy’s notes: No, they reached a point where they felt you were listing off every drug you could think of and listed only what they thought there was a good chance you’d used.

30 Response to Amy’s notes: Not entirely; they listed a bunch for me to confirm and then told my parents and my doctors that I’d been on them.

31 Probably in the trash can somewhere.

32 This is probably where they got the visual hallucinations from. It wasn’t that I saw extra people, I just thought that the strangers around me were my friends in different bodies.

33 Because my thought-fu is the strongest.

34 I have no clues what this means. So wikipedia again: “Ideas of reference and delusions of reference involve people having a belief or perception that irrelevant, unrelated or innocuous phenomena in the world refer to them directly or have special personal significance: ‘the notion that everything one perceives in the world relates to one’s own destiny’.” Yep.

35 Oh to be a fly on that wall. I don’t remember what I said, but I’ll explain the probable reason in the next chapter.

36 I don’t know how they got this so wrong. I’m 6 feet tall. Must have been slouching.

37 Hadn’t eaten much in the last two weeks.

38 I assume celsius.

39 Just check wikipedia yourself.

40 Tinea is ringworm. I can’t imagine this was an accurate diagnosis, since tinea’s a bitch to get rid of, and I wasn’t treated for it and I didn’t have it later.

41 This goes on, but it’s boring.

42 Amy’s notes: Means you’re talking to the voices in your head… if you watch me closely, most days you can see me doing this too.

43 Amy’s notes: Which is why they think you’re responding to internal stimuli—they think you’re getting your responses approved before giving them, or something like that.

44 Amy’s notes: They test this by showing you pictures and giving you lists of words and after 10+ minutes, asking you to recall the pictures or words; and, heinously, they also test this by having you count backward from 100 by sevens.

45 I included the first nerve because it’s so awesome and weird that they verify its function by my ability to detect peppermint. I’m skipping the rest of the nerves; they’ll be in the appendix if this ever takes book form. Write to me if you’re curious about the parts I’m skipping.

46 Amy’s notes: #1 is always the “actual diagnosis”—it’s what they would have sent to the insurance company—all the “rule out” are options of what you might be suffering from, if the first one proves incorrect.

47 Amy’s notes: Means they suspect you have a personality disorder, but they can’t/won’t speculate on which one; it’s very difficult to identify personality disorders in actively psychotic people.

48 This is low.

49 Amy’s notes: No, it’s very low, most people I deal with in crisis still have a GAF score around 30.

50 Amy’s notes: This is a lot, starting doses are usually 0.25mg – 0.5mg.

51 Amy’s notes: QID = four times a day; PRN = as needed.

52 Amy’s notes: Can I have one now?

I think of this as a metaphor for how I handle personal issues.

Hi there! You should totally go buy my book for the low low price of 6.73! It's like buying me a beer at an out-of-the-way dive bar in Brooklyn! Not in Manhattan. Manhattan prices are ridiculous, though there are a couple of decent Irish dives where you can snag a drink for five bucks. Otherwise, you're looking at a two or three book beer.
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