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Date:
Thu, 11 Jul 2002 12:21:16 Subject:
CLIENT ASSESSMENT REPORT #46892 From:
debarthelme@rush.edu To:
mentalhealth.autofiler@rush.edu, tabitha_moran@rush.edu
RUSH
PRESBYTERIAN HEALTH NETWORK Department
of Mental Health
ASSESSMENT
FOR PATIENT #46892
DATE: 7/11/02
NAME: Berto Tazar
SSN: 327-90-0666
REPRESENTATIVE
PAYEE: Self
ADDRESS: 4097 N. Lakeshore Drive, Suite 7082
DOB: 4/18/65
AGE: 37
SEX: M
RACE/ETHNICITY: Cauc
MARITAL
STATUS: Single
PRESENTING
PROBLEMS
Chief
Complaint: Delusions
Symptom
Inventory: Anhedonia,
Anxiety, Behavior Problems (see notes), Compulsions, Delusions, Depressed Mood,
Grief, Low Self-Esteem, Memory Problems, Paranoia, Poor Judgement, Ruminations,
Sleep Problems, Other (Extreme paranoia leads patient to refusal to communicate
directly with therapists, will communicate only "through" patient
Pedro Vasquez, whom he calls "Sancho.")
HISTORY
OF PRESENT ILLNESS
Multiple
stress factors including loss of employment & unrequited love preceded
patient's descent into a delusional state. Patient, a copywriter by trade,
began writing fantastical email messages to friends and casual acquaintances
describing a journey in the past, to 14th Century medieval Italy. What may have
started as a healthy distraction from stress factors soon became
obsessive behavior. As they become more and more violent, his medieval
fantasies also became the sole focus of his existence. Patient remained indoors
for several weeks, drawing and writing these email messages, became
increasingly withdrawn from his social contacts, and ceased his search for new
employment. His delusions culminated in a violent attack on one of his friends,
Skip Valent, who later admitted the patient. At the time of his admittance,
patient was exhibiting signs of autism, slack jaw, glazed eyes, and a total lack of
communication with admitting staff. He soon thereafter however exhibited a
violent mood swing, challenging staff to a "joust" after grabbing hold of an
orderly's broom. After this episode, patient was put in restraints, and resumed
his feigned catatonia. Patient was released from restraints 72 hours later.
Patient refuses to communicate with staff, but is reading email
messages sent to him by friends and loved ones. Patient does speak (conspiratorially)
with fellow patient Pedro Vasquez, who will be transferred early next week to a
long-term facility.
HISTORY
OF PAST PSYCHIATRIC TREATMENT None.
SUBSTANCE
ABUSE Current
drug or past alcohol use: Patient's brother, Ernesto Tazar, reports that Patient is a light drinker
and occasional marijuana smoker.
SAFETY History
of suicidal ideation or attempt:
no (though patient exhibits signs of self-neglect).
Current
suicide risk: Not at
this time
History
of homicidal ideation or attempt:
yes (Patient attacked his best friend with a bicycle lock).
Current
homicide risk: No? Patient has been generally
complacent in the treatment environment, but his delusions vary in intensity.
Risk
of other violence (arson, fire, etc.?): none while medicated.
PSYCHOSOCIAL
HISTORY
Living Arrangement: Private
home/apartment, sole occupant.
Living
environment adequate and safe:
yes (though patient has been served eviction notice, so new living arrangements
may be necessary).
Significant
events in childhood/adolescence/adulthood: Patient was physically and verbally abused as a child by
father. Said abuse was not of a sexual nature. Patient's father was
institutionalized during patient's teenage years. Patient's mother deceased in
1995.
Family History Substance
Abuse: Father
(alcoholism, drugs), Brother (alcoholism)
Mental
Illness: Father
(diagnosed schizophrenic), Brother (clinically depressed)
Medical
Illness: Mother died of
breast cancer, both grandmothers died of cancer (breast, ovarian), grandfathers
both died of heart disease.
Past/Present
Relationship with Parents:
Mother dead, father institutionalized (Woodlawn Mental Health Center, Palo
Alto, CA). No discernable present relationship with father.
Past/Present
Relationship with Siblings:
Strong relationship with brother, Ernesto (residing near Los Angeles, CA).
Distant relationship with sister, Olivia (residing near Chattanooga, TN). Both
siblings have attempted contact via email. Brother Ernesto has consulted with
attending physicians. Brother Ernesto plans to visit at start of August, may
help with living arrangements.
Significant
Relationship History:
Patient had strong relationship with deceased mother. Patient in monthly phone
contact with brother, annual contact with sister. Patient alienated from
father. Patient never married, but did have string of significant monogamous
heterosexual relationships.
Children: None.
Family
Support: Moderate
Family
Members to Involve in Treatment:
Brother -- Ernesto Tazar
Friendships: yes
#
close friends: 3-4
#
casual friends: 10-12
Support
From Friends: Moderate
(admitted with assistance of friend Skip Valent, three other friends have
visited).
Other
Social Supports: no
Relationship
Problems: Conflict
(fallout with best friend preceded hospitalization), Social Isolation (in two
months preceding hospitalization, Patient had dropped off contact with most of
his friends).
Deaths/Losses: Death of mother had significant effect,
and patient has suffered from recurring incidents of unrequited love.
Trauma
History: yes (childhood
verbal/emotional abuse, physical abuse, adulthood verbal/emotional abuse in
workplace).
Education:
highest grade: BA in
English, Italian minor, UCLA
Learning
disabled: no
Academic
Achievement Problems: no
Literate: yes
Work
History: Journalist, LA
Times (2 years), Barker, Barnum and Bailey Circus (2 Years), copywriter, OGVB
Marketing (11 years), currently unemployed
Military
Service: no
History
of Legal Problems: no
Guardianship: self
Religion/Spiritual
Beliefs: Buddhist (light
practicing)
Primary
Language: English
Primary
Culture: American
Speaks
and Understands English:
yes
Leisure
and Recreational Activities:
tai chi, creative writing (fiction), videogames, drawing
Sexually
Active: yes
Sexual
Orientation:
heterosexual
Sexual
Dysfunction: unable to
determine
MENTAL
STATUS
Appropriately
Dressed and Groomed: yes
(poor grooming upon admittance, acceptable since admittance).
Oriented
X 3: Person-yes.
Place-no. Time-no.
Speech
Activity: soft (when
speaking to fellow patient, does not speak to physicians)
Motor
Activity: appropriate
Affect: blunted
Mood: sad
Thinking: tangential
Concentration: preoccupied
Hallucinations: unable to determine
Delusions: yes
Describe: Patient believes that he is imprisoned
in 14th Century Italy, and that medical staff are his captors.
Cognitive
Functioning/Intelligence:
above average
Reasoning
Ability: confabulatory
Insight: limited
Motivation: resistive
Clinician: D. BARTHELME, MD
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