Medical Record Number: 65498321
Name: Blake, Anita
DOB: 11/ 4/75
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Date: 1/16/02
Time Evaluation Began: 0823
Mental Hygiene Arrest (MHA): Yes
Referral Source: RPIT
Mode of Arrival: police car
Current Living Situation: with roommates
Chief Complaint: violent outbursts; "I don't belong here!"
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Identifying Data:
Sex: Female
Age: 27
Race: Caucasian
Marital Status: single
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Alerts: (risk factors)
_x_ danger to self/others
___escape risk
___Criminal Procedure Law status
___ previous known adverse reactions to medications
___ physical health conditions/needs (e.g. withdrawal)
_x_ other: necromancer, vampire human servant; vampire executioner
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History of Presenting Illness: (Include a brief description of events leading to this presentation)
27 y.o. female presented to ? (psych) ED after attacking a city councilman after an altercation at a local club. RPIT brought pt. into ED stating patient has a history of violent outbursts. Pt. states that councilman was a servant of a powerful vampire and had tried to attack her and that she was defending herself and her friends.
According to police reports pt. threatened to kill councilman if he did not leave the city immediately.
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Past Psychiatric History: (Include Psychiatric Symptoms/Treatments, current provider, substance abuse, sexual abuse, legal issues)
Pt. and collateral contacts state that pt. has had no history of past ? treatment or substance abuse. Patient works as a retainer for SLPD and has no history of past legal troubles. But collateral contacts confirm that she does have a violent temper and is prone to mood swings. Pt. states that she had been in a diving accident when she was in college and as a result has a fear of enclosed spaces. She has never sought help for her panic attacks.
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Family Medical & Psychiatric History: (Include relevant family history of mental illness, drug/ETOH abuse, completed suicides, family losses, brief family medical history)
Pt. states that she has little to no contact with her biological family, which consists of father, step-mother and two half-siblings. And states that there is no history of mental illness in her family.
Pt. lost her mother d/t a car accident when she was three.
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Social History: (Consider: source of income, housing status, presence and ability to access supports, education, employment, culture, etc.) Pt. works as an animator for Animator's, Inc. here in the city and also serves as preternatural expert for the SLPD. She is also the licensed vampire executioner for the surrounding three states. She rents a home that she shares with any number of people at a time. She holds a BS in preternatural biology Pt. is also a necromancer- an ability which surfaced when she was an adolescent, and was then trained by her maternal grandmother. Pt's supports include best friend, Veronica Sims, her boyfriend of 7 months, Micah Callahan and her other boyfriend of 2 years, the vampire Jean-Claude. Pt. reports recent ending of two-year on-again-off-again relationship with another boyfriend. Pt also claims that, while she is not a lycanthrope, she is the head of the local wereleopard group and receives a great deal of support from them.
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Initial Screening Mental Status Exam: (check all that are present)
Physical Appearance:
(x) Appropriate ( ) Disheveled ( ) Bizarre
Speech:
( ) WNL ( ) Rapid (x) Hostile ( )Slurred
Thought Process:
(x)Goal Directed ( ) Tangential ( ) Concrete
( ) Loose Assoc. ( ) Perseverative ( ) Confused
Insight:
(x) WNL ( ) Poor ( ) Good
Judgement:
( ) WNL (x) Impulsive ( ) Impaired
Orientation:
(x) Person (x) Alert ( ) Delirious
(x) Place (x) Date
Memory:
Short Term: (x) Intact ( ) Not
Long Term: (x) Intact ( ) Not
Mood:
( ) WNL ( ) Depressed (x) Angry
( ) Confused ( ) Euphoric (x) Anxious
Affect:
( ) Appropriate ( ) Labile (x) Flat
( ) Constricted ( ) Incongruent
Hallucinations:
( ) Auditory ( ) Visual ( ) Tactile
( ) Olfactory ( ) Command (x) None
Delusions:
( ) None (x)Persecutory ( ) Religious
(x) Grandiose ( ) Jealous ( ) Erotomanic
Sleep:
( ) WNL ( ) Increased (x) Decreased
Appetite:
( ) WNL ( ) Increased (x) Decreased
Suicidality:
( ) Yes (x) No
Homicidality:
(x) Yes ( ) No
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Collateral Contacts:
Family Members: uncommunicative with patient for several years
Therapist: none
PCP: Dr. Lillian Gray (314) 555-7820
Other:
Boyfriend: Jean-Claude (vampire) (314) 555-3207
Boyfriend: Micah Callahan (314) 555- 7591
Friend: Veronica Sims (314) 555-9908
Co-worker: Sgt. Dolf Storr (314) 555-7748
Co-worker: Larry Kirkland (314) 555-7473
Employer: Bert Vaughn (314) 555-7473
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Evaluator Signature: Catherine Jacobs, RN, MS, NPP Date: 1/16/02 Time: 1015
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M.D. Physical Assessment Date: 1/16/02 Time Begun: 1300
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_x_ Initial Assessment Reviewed
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Studies reviewed: (For items checked note findings of significance below)
( ) CBC ( ) TSH (x) Drug Level ( ) EKG ( ) DIFF (x) ETOH ( ) Ear Oximetry (x) X-Ray ( ) Profile 6 ( ) UA ( ) Urine Chemical Dependency ( ) Other: Lycan. ( ) Profile 12 ( ) CK-MB ( ) Urine Drug Screen ( ) Other: _______
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Pending Labs obtained in E.D.: none
Ordered Labs not obtained in E.D.: none
Findings: negative for ETOH and Drug Use, negative for Lycanthropy, X-Rays show no fractures
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Physical Examination:
27 y.o. c.f with abrasions on face and hands resulting from an altercation. Right wrist is in bandages. Examination by med ED ruled out fracture, just severe sprain.
Severe scarring over left arm and shoulder. Pt. indicates that she is a survivor of multiple vampire and lycanthrope attacks.
Blood tests reveal no evidence of lycanthropy infection.
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Psychiatric Evaluation:
27 y.o. c.f. undiagnosed history of violent outbursts towards others. Patient has poor impulsivity and has expressed acute homicidality towards vampires. Because of her status as a legal vampire executioner and human servant to a vampire, pt believes that the vampire community is hunting her. Her persecutory delusion is what led to the violent outburst today.
A diving accident several years ago has resulted in the pt experiencing panic attacks in enclosed spaces.
Pt. has also recently ended a three-way relationship. Pt. is still romantically involved with one of the other participants in the relationship and is still socially involved with he other. Upon the ending of the three-way relationship, pt started dating another man and has included him the relationship with one of the first boyfriends.
Relationship poses as a stressor in pt's life as one of the boyfriends is a vampire, which helps to increases pt's persecutory delusions and causes conflicts within pt by her being a vampire executioner dating a vampire.
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Diagnosis:
Axis I (Clinical Disorders):
312.34 Intermittent Explosive Disorder
v61.10 Partner Relational Problems
300.21 Panic Disorder with Agoraphobia
309.81 Posttraumatic Stress Disorder
Axis II (Personality Disorders):
V71.09 No Diagnosis on Axis II
Axis III (General Medical Condition): None
Axis IV (Psychosocial or Environmental Problems):
* Vampire boyfriend
* Recent end of long term relationship
* Work environment supports violent and aggressive behavior
Axis V (Global Assessment of Functioning):
25 (current)
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Treatment Plan:
Because this is a first time incident and pt has a strong supportive system in place, admission is not recommended at this time. Recommend continuous out-patient services with therapist specializing in PTSD and relationship issues.
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Physician Signature: Robert W. Freedman, MD, MPH Date: 1/17/02
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Discharge Summary: Check all that apply:
( ) Admitted in Inpatient Service
Specify _________________________
(x) New Referral to Mental Health Provider
Specify: Eliza Hoffmann, MD, Ph.D. (314) 555- 4859
( ) Referred to current treatment provider
( ) Substance Abuse Services
Specify: ______________________
( ) Other
Specify: ______________________
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Discharge Plan:
* Keep appointment with Dr. Eliza Hoffman (314) 555-4859 on Wednesday Jan 23 at 2:30pm
* Call 911 if needed.
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Signature of Discharging Clinician: Alison Delarosa, CSW-R
Discharge Date: 1/16/02
Discharge Time: 1632
Author: Ekat
Date: January 2002
Rating: PG
Disclaimers:
1. Anita Blake and her universe belong to Laurell K. Hamilton.
2. The treatment form is based on the Acute Psychiatric Services Evaluation form used by Strong Memorial Hospital in Rochester, NY.
3. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) was relied upon heavily. And yes, I did read all the criteria for Anti-Social Personality Disorder (formerly called Sociopathic Personality Disorder) and she doesn't fit the criteria.
4. I just made up a last name for Dr. Lillian. And a birthdate for Anita.
5. This was inspired by a conversation on a list about Anita needing to see a therapist, and working in a Psychiatric Emergency Room, I couldn't resist.
6. For the non-medical term inclined readers ETOH= alcohol, WNL= within normal limits.
7. Warning... I am not a therapist! I just work for many of them and read evaluations at great lengths all day long.