The Episode: Interlude#
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CONDITION AT ADMISSION: Upon admission, Peter presented as a disheveled, withdrawn, guarded, and underweight young Caucasian male.12[12] He had very poor eye contact, minimal cooperation with the interview.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 123-¼ 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 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.
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Next week#
Meeting my new roommates.
I haven't used a hole punch in 16 years.