Chapter Text
PSYCHIATRIC CARE DAILY NOTE
PSYCHIATRIC SERVICES PROVIDER:
Telnorri (M.D., L.P.C., Psy.D.)
PRIMARY MEDICAL CARE PROVIDER:
Julian Bashir (MD)
SEND DIGITAL COPY TO PRIMARY CARE PROVIDER:
Yes
SESSION #:
20
DATE:
June 18, 2370
START TIME:
07:30
FINISH TIME:
08:00
Note: The session included a break, initiated by the patient, of approximately 12 minutes.
PATIENT NAME:
Garak
Note: Patient prefers to be addressed by family name only, and chose not to provide a given/personal name.
PATIENT PRONOUNS:
He, him, his
PATIENT SPECIES:
Cardassian
PATIENT AGE:
Unknown (patient declined to provide this information).
Note: patient's apparent age is equivalent to approximately 50 Terran years
SPECIAL NEEDS:
Patient requires warmer temperatures (optimal: 30-35 degrees C) and dimmer, redder lights than station standard.
ALLERGIES:
No known allergies.
PRIMARY DIAGNOSES:
12 days post OD
Primary substance: opioid (triptacederine)
Secondary substance: alcohol
Substance dependence/addiction: opioid (triptacederine)
Note: Moderate symptoms of withdrawal from triptacederine were noted upon administration of Naloxone VI.
Note: No symptoms of withdrawal from alcohol were noted at a BAL of 0.02 or at a BAL of 0.0.
ADDITIONAL DIAGNOSES:
Anxiety (moderate-severe)
Depression (moderate-severe)
Specific phobia (claustrophobia) (severe-extreme)
Probable PTSD (note: this cannot be accurately diagnosed at this time due to the patient's unwillingness to discuss his history, and reflects only this provider's assessment of patient's behaviors)
CURRENT MEDICATIONS:
Triptacederine (extended-release, sub-q): 20 cc qd
Hydrocortiline (IM): 5 cc tid
Triptacederine (short-acting, sub-q): ≤ 5 cc, bid, prn
Note: Triptacederine and hydrocortiline are both associated with increased respiratory depression when combined with alcohol. Alcohol should be limited to no more than 1 serving daily (½ cup of kanar, or equivalent), only by patient request, and only under Level 1 medical supervision.
SOCIAL HISTORY:
Patient is currently self-employed as a tailor and proprietor of Garak's Clothiers.
Patient was born and raised on Cardassia Prime
Patient was exiled from Cardassia (reason(s) unknown) in 2368 (I have not asked patient to provide further information).
Family: unknown (patient declined to provide this information)
Friends: Dr. Julian Bashir, Professor Keiko O'Brien (otherwise, unknown; patient declined to provide further information)
Education: Unknown. However, it is assumed that the patient was educated on Cardassia Prime. (I have not asked patient to provide this information). Patient is literate in at least, Kardasi and Federation Standard.
Living arrangements: Patient lives alone. Patient is currently receiving 26/7 Level 2 supportive care.
Note: It should be pointed out that patient is a Cardassian, living on a Bajoran-Federation station, with environmental controls, including those for temperature and lighting, set for Bajoran and Human comfort, amongst, primarily, Bajora and Humans.
Patient appears to have limited social support, with the exception of Dr. Bashir and Professor O'Brien (and that provided by his caregivers).
PERTINENT MEDICAL HISTORY:
Prior neural surgery: implantation of endorphin-stimulating neural implant
Activation and use of endorphin-stimulating neural implant
Dependence on/addiction to the endorphins thus generated was attained
The implant failed completely approximately six weeks ago, causing significant pain and other neurological effects
Device was deactivated.
Patient experienced severe withdrawal effects.
5.5 weeks ago, the device was removed, following stabilization of patient's medical condition.
PSYCHIATRIC HISTORY:
Significant for dependence on/addiction to endorphins generated by neural implant.
Probable depression (moderate-severe).
Probable anxiety (moderate-severe).
Probable specific phobia (claustrophobia). Severity uncertain. Patient currently presents with a severe-extreme condition, but it is possible the patient is experiencing an acute exacerbation of what is typically a less severe condition.
Probable PTSD (severity uncertain. Patient currently presents with what appears to be a moderate-severe condition, though he could be experiencing an acute exacerbation of a typically less severe condition).
COMMUNICATION:
The patient's native language is Kardasi. He speaks Federation Standard fluently, with an exceptional vocabulary. His pronunciation and, especially, intonation evidence his Kardasi native language, but do not interfere with communication. Greeting at this session, as at prior sessions, was initiated in Kardasi. Patient responded in Federation Standard, probably due to his knowledge that provider's notes will be in that language. The session was conducted in Federation Standard.
Patient's communication is notable for a pronounced preference to avoid talking about himself (specifically, any challenges or problems he may be experiencing). Patient also demonstrates a pronounced tendency to avoid any topic pertaining to emotions.
SUBJECTIVE:
Patient tolerated the majority of the session well. Patient was engaged and responsive for a significantly increased percentage of this session.
However, moderate-severe anxiety was observed during discussion, evidenced by loss of focus, agitation, and moderate hyperventilation/respiratory distress. The precise trigger was not precisely determined, other than that a significant increase in anxiety was noted concurrently with a reference to “finding the time” to prepare plans for the arboretum patient is working on with Professor O'Brien. There is a strong possibility the trigger relates to social expectations and/or time management and/or tolerance of work by duration. Tolerance of coaching in guided breathing techniques was good, and the guided breathing successful in stabilizing patient's respiration. This was followed by a self-initiated relaxation technique – namely, taking a break from the session and from interaction, and working at patient's trade.
Affect was variable, but significant for mild anxiety, escalating to moderate-severe anxiety, as described hereinabove.
Additionally, withdrawal from interaction was noticeable on several occasions, evidenced by a failure to respond and a closing of the eyes – suggestive of moderate depression and/or anxiety. Patient was consistently able to re-engage with minimal prompting.
TOPICS/GOALS ADDRESSED:
Pain management
RESPONSE:
Patient indicated that pain management, with the extended-release triptacederine and the hydrocortiline, was adequate.
Note: Patient's level of pain increased significantly subsequent to patient's increase in anxiety. Patient attempted to control pain via relaxation (taking a break and consuming rokassa juice) without noticeable success. Patient requested triptacederine, and was given a hypospray containing 10 cc and adjusted to inject 5 cc. Previously, patient was told he could take no more than 5 cc, twice per day. Patient took the initiative of adjusting the settings to instead inject 3 cc, stating, upon questioning, that he did not require the full 5 cc at the moment. Patient also took the initiative of showing this modification to this provider, prior to self-administration, for the purpose of enabling this provider to accurately record the amount taken.
TOPICS/GOALS ADDRESSED:
Patient was asked if there were any other symptoms he would like to address.
RESPONSE:
Noticeable observed increase in anxiety. However, patient hesitated and then withdrew, rather than, as is typical, declining immediately. Upon further questioning, patient declined to pursue the topic at this time.
TOPICS/GOALS ADDRESSED:
Activities: Provider asked about patient's walk yesterday with Professor O'Brien.
RESPONSE:
Patient responded with an objective statement as to specifics of the activity (≈“We saw the new stairs and we saw the site of Professor O'Brien's arboretum”), with no subjective commentary.
Upon further questioning, patient implied his approval of the stairs by stating that the stairs are well-built and of architectural merit, and his approval of the site for the arboretum by stating that it is “quite suitable”.
TOPICS/GOALS ADDRESSED:
I asked about how the project is otherwise proceeding, with a question as to the next step.
RESPONSE:
Slight withdrawal (looking away), but patient replied, stating that the Professor is preparing plans and has requested his suggestions.
I pursued, asking if he did not wish to provide suggestions.
Patient deflected, with a hostile veneer and mild anxiety, requesting that I leave him to his work.
I requested that he allow me ten more minutes, to which he reluctantly agreed, upon a second request.
I pursued questioning, asking why he did not wish to provide suggestions. Upon my query as to whether or not it was because he was concerned about finding the time, he became agitated, and experienced a moderately severe panic attack, as described hereinabove.
TOPICS/GOALS ADDRESSED: The Human process of team planning.
(Note: This provider is El-Aurian, and was not raised amongst Humans. Nor have I worked extensively on Human teams. Therefore, my explanation to patient was, by necessity, based on various observations of Human behavior and readings from Human literature, rather than first-hand knowledge.)
RESPONSE: Patient exhibited noticeable curiosity when I introduced this topic.
Patient indicated an increase in understanding of Professor O'Brien's expectations (namely, that her expectations were typical for those a Human would expect of another – not at all simplified due to patient's condition – and not condescending).
TOPICS/GOALS ADDRESSED: The merits of addressing an issue early, before it becomes a severe problem (introduced because patient was exhibiting evidence of an increase in physical discomfort/pain).
RESPONSE: Ostensible agreement and mild deflection (patient claimed to be thirsty, rather than acknowledging pain).
Patient stood, on his own initiative, and replicated a rokassa juice for himself.
Of particular note, patient subsequently offered me a beverage, and, upon my affirmative response, replicated my beverage of choice, and brought it to me.
Upon patient's return, he allowed himself to show slight discomfort/tiredness, by leaning against his cushions (previously, he had been consistently sitting upright, at his worktable).
Patient finished his juice.
His discomfort was not mitigated, and seemed to escalate.
Patient requested triptacederine.
I provided him with a 10-cc hypospray of triptacederine, set to five cc. Please see above for further discussion.
TOPICS/GOALS ADDRESSED: Activities
RESPONSE: I asked if there was anything further he wished to address; he declined.
I commented that he had begun again to work.
He visibly relaxed, and acknowledged the accuracy of that statement.
I commented that he had eaten breakfast and lunch, but not dinner, the previous day, and asked why he hadn't wanted dinner.
He replied “wasn't hungry. Tired.”
I asked “could you tell me why you did not wish to shower this morning.”
He withdrew (closed eyes).
I requested an answer and pointed out that the question was a yes- no question.
He replied that “it is entirely unsuitable”.
Upon further questioning, he indicated that it was the shower stall, and not the action of showering (or the question), that was unsuitable.
I asked if I could make a comment and offer a suggestion; he agreed.
I commented that he had probably had an unpleasant experience in the shower [note: probably due to an exacerbation of his claustrophobia, probably concurrent with the increase in anxiety/depression caused by his recent medical challenges, as cited hereinabove], and that his mind was associating the shower with that. I asked if there was anything pleasant he associated with the shower.
He replied, “sometimes”.
Further questioning indicated that he finds sonic showers aversive, but “hot water is pleasant”.
[note: I have written an order, which I've communicated to Dr. Bashir and to the station's financial department, that hot water be included as a medical, not personal, expense for him, for thirty days].
I suggested that he try to think of the combination of “hot water” and “shower” as many times as possible throughout the day.
Patient laughed at my suggestion, and stated a lack of understanding as to how that could be beneficial.
I explained that it is a means of developing a strong positive association with something that is currently aversive.
Patient asked if this process alone would make the shower tolerable.
I replied that it would not, unless his objection were solely to the sonic shower or to cold water.
Patient admitted that it was not.
I made the further suggestion that he could acclimate himself gradually through intentional gradual increase of exposure (approach increasingly closely, stay for an increasing duration of time)
Patient understood and expanded (adding the steps of stepping in and out, without the necessity of staying within for the duration of a shower).
Patient acknowledged that that “could be helpful”.
Nurse Heyns returned at that time. I thanked patient for his time and consideration – and he thanked me.
RECOMMENDATIONS:
Continue with the current frequency and duration of counseling sessions. Within the sessions, continue to address issues pertaining to the management/mitigation of patient's medical challenges. Continue to address self-advocacy skills. Continue to address skills pertaining to tolerance of and independence at the performance of necessary activities of daily living.
The next session is scheduled for 18:00-18:30 this evening.
Continue to maintain the patient's current level of support. Patient is tolerating well the support of both of his home health aides, Nurse Taya Patel and Nurse Dezi Heyns, as well as Dr. Julian Bashir, who is currently serving, unofficially, in the capacity of home health aide, as well as, officially, doctor. At least one additional home health aide will need to be placed within seven days unless patient's recommended level of support is decreased.
Supervision will be maintained at Level 2 until stability/balance upon rising and independence at consuming adequate quantities of foods, as well as liquids, is attained. At that time, level of supervision shall be re-evaluated, taking into consideration patient's level of functioning as well as potential effects of prescribed medications.
PROGNOSIS:
Patient's prognosis is good, so long as adequate support is maintained for as long as necessary.
Telnorri, M.D., L.P.C., Psy.D.
Counselor, Deep Space Nine