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Intake Date: October 2021

IDENTIFYING/DEMOGRAPHIC DATA: This was an emergency, voluntary admission for this 28-year-old single white female. This was her fourth psychiatric hospitalization. Susan lives with a 24-year old female roommate in New York City. She has a bachelor’s degree in art history and is employed by a major New York museum. Susan is of Jewish ancestry.

CHIEF COMPLAINT/PRESENTING PROBLEM: “My therapist said I was decompensating because I broke my leg, and I was despondent.”

HISTORY OF PRESENT ILLNESS: Susan reported she began a Noom diet and, although she was supposed to be eating 600 calories a day, she was only eating between 200 and 400 calories a day. She also admitted to purging and frequent use of laxatives. Susan reported her weight was being monitored, and she had lab work done to be sure she remained healthy. In 3 months, Susan lost approximately 80 pounds. Susan reports she has a very stressful job. She stated that approximately one month prior to admission, she started to “decompensate” and had difficulty maintaining control at work. She had several altercations with coworkers. One week prior to admission, Susan reported her NA sponsor “said something nasty, and I lost it.” According to her mother, the sponsor made a reference to Susan being overweight. Susan reported that she was angry and “hit everything I knew I could—but that did not help.” She then kicked a brick wall, fracturing her right leg. Susan also reported being under stress due to applying for her master’s degree in art history and difficulties with her boyfriend.

Susan complained of depression with insomnia and sleeping only a few hours per night, feeling confused, decreased concentration, irritability, anger, and frustration. She admitted to suicidal ideation. She complained of feeling paranoid over the past few weeks and believed the police were after her and that she heard them outside her door. She believed the police had her under surveillance. Susan also complained of a fear of dirt, taking time to frequently bathe and brush her teeth, which slowed her down many times.

PAST PSYCHIATRIC HISTORY: Susan’s mother reported that Susan saw a clinical social worker briefly when Susan was 10 years old because she was acting out. Susan reported that she was hospitalized at a New York hospital 3 years ago for 3 months. Six months after that, Susan took an overdose of Halcion and was treated at the same hospital, and then was transferred to a state hospital. After discharge in the next month, Susan attended a partial hospitalization program for drugs and alcohol every day for 5 weeks. She also saw a psychiatrist for 2 years. Two years after that, Susan saw a clinical social worker and psychiatrist and continues to the present with them.

Susan reported a history of bulimia since the age of 17 bingeing, purging, and the use of laxatives. She reported she had not purged for 3 years until she began the Noom diet 3 months ago. Although Susan is currently not bingeing, she admitted to purging and using laxatives. 

SUBSTANCE USE HISTORY: Susan admitted to using marijuana, cocaine, opiates, and hallucinogens in the past. She denied IV drug use but admitted to “skin popping” cocaine. Susan has abused alcohol in the past. According to her mother, Susan has also abused prescription medications in the past. Susan reported that she has been clean and sober for the past 2 years and attends AA and NA meetings regularly. She also complained of panic attacks and reported that she controlled them by taking Klonopin, but there was no clear information about this.

PAST MEDICAL HISTORY: Susan is allergic to penicillin and has a lactose intolerance. She wears glasses for reading.

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Susan’s parents were married when her mother was 19 years old, and Susan was born the following year. Susan’s mother described Susan as a wonderful, even-tempered, and happy baby. Two years later, Susan’s sister was born. Mother stated Susan became stubborn and difficult. Susan’s mother stated her marriage was conflicted because she has a communication problem with her husband and he was “never an active parent.” When Susan was 12 years old, her parents separated for 2 weeks.

Susan reported her mother quit college after Susan’s birth and returned to college after her sister’s birth. She said her father worked all the time, and there was a housekeeper who cared for the children. The family moved to Arizona when Susan was in sixth grade, where she began using marijuana that she reported stealing from her parents. The family returned to New York when Susan was in seventh grade.

CURRENT FAMILY ISSUES AND DYNAMICS: Susan is currently applying for admission to graduate school and has taken some courses toward her master’s degree. Susan lived in Connecticut during college had many friends and was active in NA and AA. Susan indicated she was happy living in Connecticut and felt returning to New York was “a stupid mistake.” Susan reported that she currently has financial problems because of money owed to her therapist and the hospital in New York.

MENTAL STATUS EXAMINATION: Susan presented as an obese, somewhat disheveled, white female who had a cast on her right leg. She was relaxed but very restless during the interview. Her facial expression was mobile. Her affect during the interview was constricted and her mood dysphoric. Later her affect became full range and her mood very liable. Susan’s speech was pressured and often circumstantial or tangential, and she spoke in a loud voice. At times her thinking was logical, and at other times it was illogical. Susan denied hallucinations but complained of hearing policemen outside her door prior to admission. She denied homicidal ideation and initially admitted to suicidal ideation but then denied this. Susan was oriented to person, place, and time. Her fund of knowledge was excellent. Susan was able to calculate serial sevens easily and accurately. She repeated 7 digits forward and 3 in reverse. Her recent and remote memory was intact, and she recalled 3 items after five minutes. Susan was able to give appropriate interpretations for 3 of 3 proverbs. Her social and personal judgment was appropriate. Susan’s three wishes were: “To be skinny, to have a big house where I can take in all the stray cats, and for a million more wishes.” When asked how she sees herself in 5 years, Susan replied, “Hopefully graduating from graduate school.”

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