Soon after I was discharged from McLean in 2011, I submitted a request to get a copy of my medical records. A huge pile of paper was mailed to me. When I first read them, I was overwhelmed with the “professional,” “structural,” and “brief” tone they have. I was also sometimes surprised by what was documented. Recently, I talked to a research doctor and mentioned that I had read my own medical records. She did not expect that and said, “Reading one’s own medical records is not easy. They are usually technical. And rushed. Often with mistakes.” I agreed. Very often, a lot has to be done in a very short time.
However, these medical records shaded some important light on how I was perceived and expected to behave when I first came in contact with the caregivers at McLean, people who knew about mental illness but did not know me personally. That is invaluable.
Identification Data and Chief complaint: This is a 37-year-old, Asian-American female with a history of schizophrenia, who presents for her first McLean, and likely her first lifetime hospitalization for increasing psychotic symptoms in the context of stopping her Zyprexa.
History of Present Illness: Please note that, on arrival to the CEC, the patient was very sedated and unable to participate in the interview in a meaningful way. She nodded “no” to questions about suicidality and drug allergies but was unable to really give much information beyond that overnight. (Mindy’s note: This was in the middle of the night after I went to the ER and was moved to another location that I don’t remember at all.) The remainder of this note will come from information obtained in the APS. This is a 37-year-old, Asian-American female with a history of schizophrenia with no previous hospitalizations, and no significant past medical history, who was brought in by EMS after the patient’s friend called 911 because the patient had been worsening in terms of her schizophrenia. The patient has been off of her Zyprexa, which was at a dose of 2.5 mg daily. However, her symptoms worsened in the past few weeks. Per her friend and the patient, she recently quit her job because she “wasn’t performing well” and has been spending the past week at home alone with increased auditory hallucinations hearing six or seven different voices. Per her cousin, the patient has been afraid of being attacked and was reusing to allow her parents to visit. (Mindy’s note: this is not accurate. My parents does not usually come and visit me. They live far away. It was strange that they wanted to drive 5 hours on a weekday without advance notice to visit me! Their visit is the unusual part, if you knew us.) Also, has been worried about being stalked. The patient’s parents report concern about the patient being at risk for suicidality given her degree of confusion and distress. (Mindy’s note: I was shocked when I saw this! Shocked. Obviously, this was from someone who did not know me well.) One month ago, the patient was brought to the Emergency Department status post taking sleeping pills, which she reports was not an overdose, but the patient left from the Emergency Room without being hospitalized. The patient denied suicidal or homicidal ideation in the APS but reports “perhaps” that she has had command auditory hallucinations of suicide. (Mindy’s note: Again. Shocked and not sure who said this!) She denies visual hallucinations or ideas of reference. She reports sometimes feeling stalked and sometimes feeling like she can read people’s thoughts, “But you can’t confirm that sort of things.” Collateral from the patient’s close friend and coworker report that this coworker has been in touch with the patient’s family, and they believe that she has been off of her medication for the past six months. One month ago, her condition worsened, and she reportedly became confused and began calling people in the middle of the night (Mindy’s note: I called two people. One at midnight one at 2am.) saying she was hearing voices and being talked, and around that time she took the sleeping pills. They tried to get her to the ED, but she ended up running away. (Mindy’s note: I did not “run” away. I walked away on my free will after speaking to someone who wanted to me follow her to the ED. I disagreed with her suggestion.) The coworker feels that the patient is not safe at home, and the friend called 911 today because the patient did not recognize her when she saw her. (Mindy’s note: I am pretty sure this was referring to a phone call…I did not see any friend that day.)
Mental status examination on admission: The patient is a thin, Asian-American woman in hospital attire. She is sedated and minimally responsive to verbal stimuli. She will nod “yes” or “no” to safety questions, but she refuses to answer further. No speech is observed. Her mood, thought process, and thought content are unable to be assessed. Thought content likely is significant for an underlying psychotic process, and this interviewer questions if some of what appear to be sedation are underlying psychotic symptoms. Insight and judgement is limited by sedation at this time. Attention, orientation, and memory were unable to be assessed secondary to the patient’s sedation.
Inventory of assets: The patient is reported to be bright and articulate with good social and family support.
Formulation: This is a 37-year-old female with a history of schizophrenia currently decompensated with increased psychotic symptoms in the setting of stopping Zyprexa with hopes to conceive a child. Her family and friends are concerned about her safety and recent erratic behavior and brought her to medical attention. In the APS, she was given 5mg of oral Zyprexa and is currently sedated in the CEC and unable to participate in the interview in a meaningful way. This lack of participation may also be representative of her underlying psychotic process. She requires an inpatient level of care for safety, stabilization, medication re-initiation and management, diagnostic clarification, and aftercare planning.
Initial treatment plan: To admit the patient to AB2. Estimated length of stay of seven to 10 days. We will put her on 15-minute checks while restricted. Initial short-term goals are safety and stabilization. Recommended interventions include individual case management, group therapy, milieu therapy, pharmacotherapy, family meeting, medication management, and psychosocial interventions. (Mindy’s note: This is amazing! A plan of action!)
Note: Some part of the admission note report has been emitted here.
As someone had a broken brain, I was not consulted. They couldn’t; I was sedated. But they had to do something. The had to help me. My life and health status was pieced together by friends some knew me more than others. Mixed in this report includes some facts, some assumptions, and some of their personal worries projected onto my situation. However, very often, records like this overrides voices from people like me. It was my (lack of) voice against everyone who loved me.
Reading this report, I also gained a tremendous respect for the attendings at the ER, CEC (Clinical Evaluation Center at McLean), and APS (Acute Psychiatry Service at MGH). Overnight, they had an idea of who I was. They made the best decision about my life by digging up as much information as they could. They do this every day! They help people.
I am lucky in that I gained my own voice back. As the caregivers looked after me for two weeks, they formed first-hand perspectives about me. I think they got a better picture of me. Not everyone is so lucky and gets a chance to express who they truly are. Sometimes, medical records get passed on and on.
Let us all be mindful of what we project on others, say or assume about them. Words matter.