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—o()o—

 

CEDAR WILLOWS PSYCHIATRIC HOSPITAL

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Carlos Juan Alvarez | d.o.b. 5/4/1975 | 35 | M | Catholic | S | 513.99.2617 | DF3259 |
Staff Name: Dr. Brian Radcliff, MD | Data Entry Type: Intake assessment |
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Presenting History:

Sgt. Alvarez is a Special Forces soldier referred from the Boston Healthcare VA system following a serious self-harm attempt—?suicide attempt—committed 2 weeks ago. Deep transverse wrist lacs, R > L. Extensive tendon damage R wrist requiring surgery. L side largely soft tissue damage, sutured. Post-op POP cast R arm.

Patient said he "could not go on" and "wanted it all to stop". Admits to poor sleep, nightmares, low mood, anxiety, but denies other depressive symptoms. Answers many questions with "probably" or "si, maybe". Difficult historian. Time-frame of symptoms unclear—?present several weeks ?several months. Denies prior self-harm or suicide attempts, also denies recent acute stressors. Does not appear to regret actions and although denies ongoing suicidal ideation or intent, still appears at risk, saying "I would do it again if I must".

No evidence of manic Sx, psychotic Sx, panic or OCD Sx. PTSD screening negative but patient not v. cooperative - ?concealing Sx.

Collateral taken at Boston Healthcare by the attending physician Mjr. J. McAllister, from Sgt. Alvarez's C.O. Lt. Col. Travis: Col. Travis stated he had "no idea" why Sgt. Alvarez had self-harmed, appeared angered by his behavior. Denied any recent additional stressors affecting Sgt. Alvarez: "We're Special Forces, we're always f— stressed". Col. Travis apparently seemed largely concerned about length of Sgt. Alvarez's recovery—terminated interview when Mjr. McAllister was unable to give definitive reassurance Sgt. Alvarez would regain full function in R hand.

Mental State Examination:

On admission, patient was dressed in civilian clothing (t-shirt, jeans, boots, jacket loose over cast on R arm). Appeared underweight but well hydrated. Personal hygiene and grooming good. Wore a leather cowboy hat throughout assessment and refused to remove this, often using it to avoid eye contact. Appeared guarded, sometimes evasive and vague. Rapport was superficial. No abnormal or bizarre behavior but slight psychomotor slowing with little spontaneous activity.

Speech was soft and accented. Poverty of speech overall—brief or monosyllabic replies. Generally unspontaneous but responded to questions appropriately.

Mood appeared dysthymic although said he felt "okay". Affect was restricted in range and somewhat unreactive, but congruous.

Thought form appeared normal other than possible poverty of thought—but ?? deliberately unresponsive. No thought blocking.

Thought content hard to determine due to patient's guardedness. Denied depressive or anxious ruminations or delusional ideation. Denied current ideas of suicide or self harm, or ideas/intent to harm others or act aggressively. Possible persecutory ideas—suspicious on occasions. But denied persecutory delusions on questioning.

Cognition not formally tested. Oriented to person, place, time. Reasonably alert but concentration ?slightly reduced (possible effect of meds). Short-term memory intact, long-term memory not evaluated.

Insight—grossly intact but difficult to determine due to guardedness. Judgement clearly recently impaired (self harm) but currently seems intact.

Diagnosis: ? PTSD with underlying Paranoid Personality Disorder. ? Major Depression or Dysthymia.

Risk scores:
Risk to self—?moderate (unclear)
Risk to others—low
Risk of impaired self care—low

 


 

 —o()o—

 

Dr. Zoe Benson chewed the end of her pen, looking back over Brian's admission note. He was thorough enough, but he tended to plod his way through assessments in a concrete manner, rather than being curious and really trying to understand the person he was interviewing. It was common enough in residents early on in their training, and Brian had transferred across from surgery, where pragmatics tended to trump a more intuitive approach.

So Carlos Alvarez was Special Forces—interesting. Zoe wondered if that was what had set Jake off, whether he'd picked up a military vibe somehow. She'd just come from calming Jake down after he burst into her office, full of wild ideas and paranoia about the new admission. At least Alvarez was real—Jake had been half-convinced he was another hallucination, like the four team-mates he already said he saw and talked to every day. Jake was adamant that he'd served with them and they'd been killed, but that was probably delusional. Now he was incorporating Alvarez into his beliefs, and Zoe needed to intervene before it escalated.

Jake's fears weren't based in reality, but Zoe had the feeling there was more going on with Carlos Alvarez than they knew. The nature of the lacerations was odd, for one thing. People often cut transversely across the wrist, as Alvarez had done, as they didn't realize the artery ran longitudinally and the tendons protected it, tending to be sliced through before the knife or razor blade got anywhere near a major blood vessel. But Carlos had been Special Forces, and that meant he was smart, and well versed in how to use a knife for bloodletting. Maybe it hadn't been a suicide attempt at all? Also, he was right-handed, and people usually cut the left side more deeply as they were better with their dominant hand. Alvarez had mostly severed the tendons on his right wrist, though. Had he damaged his dominant hand deliberately?

Zoe put down the pen. She was going to need to see him. And, if possible, to get him to talk with Jake.

 

—o()o—

 

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Carlos Juan Alvarez | d.o.b. 5/4/1975 | 35 | M | Catholic | S | 513.99.2617 | DF3259 |
Staff Name: Dr. Zoe Benson, MD | Data Entry Type: Review |
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Post-Intake Review:

Interview with Sgt. Carlos Alvarez. Carlos was initially reluctant to talk but gradually relaxed a little and we developed better rapport. When asked what he had meant by "I wanted it all to stop", he said again that he could not go on. Further discussion clarified that this was not suicidal intent, but rather a post-traumatic reaction to his role as a Special Forces soldier. He denied active suicidal ideation and, although he was cautious and did not state this directly, it seems likely that the self harm to his wrists was an attempt to end his career as a sniper, rather than to end his life. Carlos appeared anxious that I might convey this to his former commanding officer, and I reassured him that his treatment was entirely confidential. He responded to that, becoming calmer and more cooperative with the interview.

From this assessment, there are no definite symptoms of a major depression, nor of psychosis. Carlos does have symptoms of PTSD, with poor sleep, nightmares and hypervigilance. I was not able to determine any triggering stimuli for flashbacks as he became more withdrawn and uncommunicative when asked about past traumas.

I checked his knowledge about the tendon damage to his R wrist, explaining that he would probably recover almost full function in his R hand, with physical therapy. He seemed a little ambivalent about this, which confirmed my impression that the self-harm was probably not a suicide attempt but done to prevent him using a sniper rifle. However, on balance he seemed relieved, as clearly if he is leaving the military he will need to find work of some kind.

Mental State Examination:

Carlos was dressed in hospital scrubs with his hair tied back. He was wearing the cowboy hat described by Dr. Radcliff, but eventually removed this on my request so that we could talk more easily. Rapport was initially difficult to establish, but improved as the assessment progressed, although he remained somewhat subdued. Carlos spoke softly but fluently, and his thinking was logical and goal directed. No abnormal ideas or perceptions were noted, although he remained reluctant to discuss past traumas. He appeared mildly dysthymic in mood, and said he was "a little down". His affect became more reactive through the interview, and was appropriate at all times. Cognition was not evaluated but appeared fully intact. His insight seemed good, and his judgement intact, although this is hard to be certain about until we can gain his trust and clarify the reasons for his self harm. My current impression, however, is that in this setting the risks of him repeating the self harm are low, and that he poses no risk to others.

Diagnosis: Self harm due to Post Traumatic Stress Disorder
Differentials: Adjustment disorder with mixed disturbance of emotions and conduct,
Possible Dysthymia.

Risk scores:
Risk to self—low unless he returns to active service
Risk to others—low
Risk of impaired self care—low

 


 

—o()o—

 

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Carlos Juan Alvarez | d.o.b. 5/4/1975 | 35 | M | Catholic | S | 513.99.2617 | DF3259 |
Staff Name: Mimi Noakes, RN | Data Entry Type: Case note |
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Phone call from Carlos's sister Gabriella.

She was alerted regarding Carlos's admission through military channels and has spoken with him, then called back asking when he would be discharged.

Explained to her that he's likely to be kept in a little longer as he may still be at risk and hasn't been fully assessed as yet.

She asked what he had done and what his diagnosis was. Explained I was not able to divulge personal details but that his condition was stable and his injuries healing well with no sign of infection. I asked if she wanted to meet with his doctor but she said she did not live locally. Said she'd come and take him to his home and stay with him, when he was ready for discharge.

Sounded caring and supportive, and having a responsible adult able to monitor him post-discharge should make that process easier and reduce the risks. Left her phone number (as in file) and is to be his main next of kin contact as his mother is too distressed and has limited English.

 


 

—o()o—

 

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Jacob Kenneth Jensen | d.o.b. 6/13/1981 | 29 | M | Nil | S | 498.60.0200 | DB1664 |
Staff Name: Dr. Zoe Benson, MD | Data Entry Type: Review
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Progress Report:

Jake is gradually improving, but remains fragile and prone to setbacks. He continues to experience visual hallucinations of his former team-mates and to interact with these non-apparent stimuli. His chronic PTSD symptoms continue—hypervigilance, flashbacks especially if triggered by certain sounds, poor sleep and occasional nightmares.

However, after his fears were allayed by meeting the new patient, Carlos, he appears to have struck up an acquaintance with him, which will hopefully be good for both of them. Jake has been avoidant of social contacts and communicating mostly with his unseen team-mates, so any attempt at a connection in the real world is a positive change.

Mental State Examination:

Jake was initially slouched in his chair, but rapidly became restless as is usual for him, changing posture frequently. He often tapped his foot and sometimes glanced into the corners of the room, probably in response to unseen stimuli. He was mildly distractible but was cooperative and spontaneous, using humor to manage his anxiety. Rapport was good.
Speech was garrulous and thought-form largely to the point, with only occasional asides directed at unseen companions. No delusional ideas expressed except regarding the reality of his ex-team-mates. His mood was brittle – superficially chatty and upbeat, with underlying anxiety.
He was alert, hypervigilant, with slightly impaired concentration due to distractibility, but cognitively otherwise intact.
His insight was good, other than regarding his abnormal perceptions. Judgement was intact and the risks were low during the assessment, but he remains easily triggered.

Diagnosis: Main Axis I diagnosis continues to be unclear.
Differentials: Schizophrenia or Psychosis NOS (not otherwise specified)
Chronic PTSD continues to be an additional diagnosis, with possible underlying ADHD.

Risk scores:
Risk to self—low (but can deteriorate suddenly)
Risk to others—low
Risk of impaired self care—low

 


 

—o()o—

 

The coffee had cooled a little but many sleep-deprived years as a resident and now a psychiatrist had taught Zoe to drink it however it came. She re-read Jake's review, dissatisfied. The real issues were never really spelled out in the records—like the unusual vividness of his hallucinations of former team-mates, and the way he interacted with them. Then there were the repeated denials from military records departments that he'd ever served in the armed forces, despite what seemed to Zoe and others to be obvious military training. Not to mention the PTSD. Jake had his ghosts, but it was like he was a phantom, too.

Carlos was another mystery, and Zoe wondered for a moment if that was why he and Jake had hit it off. There was no doubt about Carlos's military service, but by rights he should be in the VA psych hospital up in Boston. Instead, he'd been referred out to this civilian backwater in New Hampshire. No family nearby—his family lived far further south, according to Mimi Noakes who'd talked with his sister—and again, when Zoe'd tried to ask the Boston VA people why he'd been sent to Cedar Willows she got the goddamn runaround. Given what he'd done to himself, Zoe wondered if his old C.O.—who sounded like a dick, reading between the lines of Mjr. McAllister's referral—had deliberately sidelined Carlos to shut him up. Or maybe Carlos himself had forced the transfer to get away from anything military. Maybe Carlos had called in some markers or made some kind of whistleblowing threats to get out of the whole VA system, where Col. Travis could keep tabs on him far more easily.

Zoe stretched and yawned, then knocked back the tepid coffee. It was all speculation. If Carlos ever trusted them enough, maybe one day he'd tell them himself. For Jake's sake she couldn't help but be glad Carlos had ended up here, whatever the reason. And glad for Carlos, as well.

 

—o()o—

 

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Jacob Kenneth Jensen | d.o.b. 6/13/1981 | 29 | M | Nil | S | 498.60.0200 | DB1664 |
Staff Name: Dr. Zoe Benson, MD | Data Entry Type: Case note
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Jake is considerably more settled now that some time has passed since the fire in the kitchens. As before, it was the sirens that triggered him. This episode has not set him back as much as past incidents, due to support from Carlos Alvarez, his fellow patient. Jake once again regressed and seemed to be experiencing flashbacks, but Carlos's presence helped orient Jake and limited the severity of the reaction, allowing him to recover more quickly. They have developed a friendship, and Carlos has found accommodation locally so as to continue his therapy and follow-up at the hospital.

Jake's sister is coming to visit again tomorrow, and Carlos's sister arrives tonight so as to help him move to an apartment in town. At today's staff meeting we discussed introducing them to each other for mutual support, even though Gabriella cannot stay long. Carlos is likely to be discharged before the end of the week, but Jake, although naturally anxious, seems to be coping with the idea of that change. He says Carlos will visit him often and even asked if he could get a day-pass to spend time at Carlos's "pad". I have said that it will depend on his coping on the day in question, but that in principle I support Jake starting to have day-releases. Medication remains unaltered, and he is tolerating it well.

 


 

—o()o—


The new admission had taken longer than Zoe'd expected, what with the six family members who'd accompanied her, and having explain to her and the family more than once that no, she couldn't have Buttons the Chihuahua with her in hospital, no matter how cute he was.

Zoe entered the nursing station and looked out through the glass observation window, noticing Carlos sitting with a small, dark-haired woman—presumably Gabriella—who was talking earnestly, gesticulating. As Zoe watched she pulled Carlos into a hug, then drew back, waving her hands, and cuffed the back of his head. A typical big sister, then. Zoe grinned.

Not far away from their table, Jake sat with his sister and niece, playing cards—probably Go Fish from the look of it. He'd dealt in two extra hands and was chatting away animatedly, hugging his niece close and consulting her about which card to play. As Zoe watched he covered her eyes with his hand and frowned disapprovingly at thin air, admonishing the vacant chair beside him at the table—presumably one of his unseen team-mates had said or done something Jake thought inappropriate for a child's eyes or ears.

There were two empty seats at the table and Jake was playing their cards for them. Zoe wondered which of the team were sharing the visit with Jake and his family. Was it Pooch, the driver and pilot? Or maybe it was Roque, knives all hidden in deference to the civilians. Maybe it was the sniper, Aisha, if she wasn't off hanging out with Cougar. Then again, Jake had complained before now that he'd had to tell Clay and Aisha to knock off the PDAs in front of his niece, so maybe they were making out, putting on a show to get a rise out of him.

Zoe rolled her eyes at herself for buying into Jake's hallucinations—his certainty was compelling. If she squinted a little, she could almost see Jake's phantom team-mates right there alongside his sister and niece, or sitting with Carlos and Gabriella at the next table. She turned to go—it was okay to leave them; they weren't alone. Families came in all shapes and sizes, after all. Jake's family might be a little more extended than most, but at least they kept in touch.

 

—o()o—

the end