Inuyasha | Rhapsody in Eight Movements

[luxken27fics]

Title: Rhapsody in Eight Movements
Author: LuxKen27
Fandom: Inuyasha
Universe: Alternate (modern day Japan)
Genre: Mystery, Suspense
Rating: T
Warning(s): Mentions of death, the treatment of mental illnesses
Summary: When a mysterious man washes ashore on Halloween night, it becomes a race against time to uncover his identity – and the circumstances that left him there.

Author’s Note: Further author's notes for this story can be found here.


CONFIDENTAL INFORMATION
Tōkyō Ika Daigaku – University Hospital
Clinical Assessment
Psychiatry (Inpatient)

NAME: daredare だれだれ
DATE: 07 November 2005
CASE: #009572650-7748

IDENTIFYING INFORMATION
DOB/AGE: Unknown, age approximately 25 (born 1980)
GENDER: Male
RACE: Caucasian (non-Asian)
MARITAL STATUS: Unknown

ADDRESS: Unknown; currently residing at C6-25 in seclusion (safety measure)
PHONE: 8-7724 (hospital)
INSURANCE: None
LIVING SITUATION: Previous living situation unknown at this time; non-native

SIGNIFICANT OTHER (CONTACT PERSON): Unknown; medical decision makers = primary care team


CURRENT SYMPTOMS
DEPRESSION: (+) decreased interest, (+) loss of energy, (+) agitation, history unknown
SUICIDAL/HOMICIDAL: (?) SI/plan/intent/attempt, no known HI
MANIA: (+) sleeplessness, (+) distractibility, (+) agitation, history unknown
ANXIETY: (?) re-experiencing traumatic event, (+) recurrent thoughts/activities
Possible/probable, as patient is currently engaged in impulsive, repetitive drawing
PSYCHOSIS: (+) suspiciousness/paranoia, (+) social withdrawal; history unknown
ORGANIC: (+) confusion, (+) memory loss, (+) disorientation x2
Patient survived attempted drowning; current symptoms possibly related to post-event trauma
SOMATIZATION: N/A


SUBSTANCE ABUSE HISTORY
ETOH: Unknown
HEROIN: Unknown
MARIJUANA: Unknown
COCAINE: Unknown
HALLUCINOGENS: Unknown
CAFFEINE: Unknown
TOBACCO: Unknown

DOES PATIENT HAVE PROBLEM WITH SA? Unknown at this time; UDS negative (repeat x 3 – in ER, ICU, step-down, and inpatient unit)

MEDICAL HISTORY
DATE/LOCATION OF LAST PHYSICAL EXAM: 07 November 2005, Ward C6 Room 25

REVIEW OF SYMPTOMS: (+) anemia, (+) hypotension; all other systems negative

SURGICAL HISTORY: Unknown; physical did not yield evidence of procedures prior to this hospitalization
TRAUMA HISTORY: Attempted drowning, 31 October 2005
ALLERGIES: NKDA
CURRENT MEDICATIONS: (+) metabolic supplements (PO; IV discontinued in step-down unit)


PSYCHIATRIC HISTORY
PRIOR INPATIENT HOSPITALIZATIONS (PLEASE SPECIFY): Unknown
DATE/LOCATION OF FIRST HOSPITALIZATION: Unknown
SYMPTOMS AT TIME OF FIRST HOSPITALIZATION: Unknown

SUBJECTIVE – HELPFUL TREATMENTS: Unknown (possibly none)
PSYCHIATRIC MEDICATION HISTORY: Unknown (possibly none)
ADVERSE REACTIONS TO PSYCHIATRIC MEDICATIONS: Unknown (possibly none)


FAMILY/SOCIAL HISTORY
# OF YEARS OF EDUCATION: high school graduate (possibly college graduate)
SPECIAL TRAINING: current/past student at music conservatory

VOCATIONAL HISTORY: Unknown

PREVIOUS INCOME SUPPORT: Family support (presumed)

MILITARY HISTORY: Unknown

LEGAL HISTORY: Non-native to Japan; no known legal history in this country

RELIGION: None; patient has been visited by every religious affiliation at the hospital but has shown little to no interest in any of them

RECREATION: drawing, playing piano

FAMILY PSYCHIATRIC HISTORY: Unknown

# OF BROTHERS / # OF SISTERS: 1 brother
BIRTH ORDER: (?) of 2
RELATIONSHIP WITH SIBLINGS: Unknown
RELATIONSHIP WITH MOTHER: Unknown
RELATIONSHIP WITH FATHER: Unknown

HISTORY OF ABUSE (PHYSICAL/SEXUAL): Unknown/ unlikely (physical exam/questioning unrevealing)

SUBJECTIVE – CHILDHOOD EXPERIENCE: “Good”
SUBJECTIVE – ADOLSCENT EXPERIENCE: “Pressured”
SUBJECTIVE – SCHOOL PERFORMANCE: “Good”
SUBJECTIVE – ADULT EXPERIENCE: Unknown/no answer (extension of adolescence – resident’s opinion)

CURRENT FRIENDSHIPS: Unknown
CURRENT ACTIVITIES: art, music (piano)

# OF MARRIAGES/LONG-TERM RELATIONSHIPS: Unknown
# OF CHILDREN (AGES): Unknown
CURRENT RELATIONSHIP WITH CHILDREN: Unknown


MENTAL STATUS EXAM
APPEARANCE: (+) clean (dressed in hospital gown, sitting upright in bed)
DEMEANOR: (+) distant, (+) guarded
SPEECH: (+) latency
MOTOR: Normal
AFFECT: (+) flat/blunted, (+) constricted (appears emotionless, even when speaking)
THOUGHT PROCESS: (+) goal-directed, (+) concrete vs abstract capacity
THOUGHT CONTENT: (?) SI/intent/plan, (?) obsessive thoughts (no AH/VH or evidence of delusions)
COGNITIVE FUNCTIONING: oriented x 2 (place, time), (+) decreased memory, (+) decreased concentration
OTHER MSE FINDINGS: Appropriate intelligence, MMSE = 27/30 (failed long-term memory task), has capacity to make decisions, but is still under the authority of his primary care team from the Hospitalist service


CHIEF COMPLAINT
Mute, disoriented, possibly dissociative patient found down after attempted drowning, with no memory of events prior to this hospitalization. Inpatient Psychiatry was consulted during ICU stay for evaluation of SI intent/plan/attempt, as well as possible psychological trauma prior to this hospitalization (if this wasn’t an SI event). Psychiatry agreed to transfer this patient to their service once medically cleared.

HEIGHT: 193 cm
WEIGHT: 68 kg
BP: 99/60


HISTORY OF PRESENT ILLNESS/MEDICAL DECISION MAKING:

This is an approximately 25-year-old Caucasian male (non-Asian descent) with unknown PMH who was found down on 31 October 2005 after attempted drowning. Patient was originally thought to be deceased, but spontaneously revived upon examination by hospital coroner. Patient was then transferred to ER for physical exam and standard work-up, mindful of possible trauma related to his attempted drowning. He was found to be hypoxic, anemic, and hypotensive, prompting transfer to ICU under the supervision of the Pulmonary service.

Patient’s stay in the ICU was remarkable for pressor support (x3) over 3 days, with 2 successful transfusions of FPP/RBC. Patient was intubated 31 October 2005 in ER for failure to protect airway and extubated on 4 November 2005 following repeat chest x-rays that ruled out pneumonia. Patient was pancultured x 3, all with negative growth, and thus, was never on antibiotic/antifungal/antimicrobial therapy. Once hemodynamically stable & pulmonary edema resolved, he was cleared for transfer to pulmonary step-down unit until a bed was available in psychiatric unit.

While in the ICU, patient was taken for CT head (w/wo contrast), abdomen/pelvis (wo contrast) and US abdomen; all tests returned unremarkable, suggesting no previous physical trauma prior to drowning event. Patient also received an MRI brain (w/wo contrast), and completed an EEG study with the Neurology service, with similarly unrevealing findings. There was no evidence of prior/current seizure activity or long-term damage to the brain. It seems unlikely that his continued memory deficits are related to any head trauma.

Attempts to discover this patient’s identity have been futile. He was found down with no identification, and appears to have no memory of who he is, where he came from, or why he is currently in Japan. All medical decisions made on his behalf were consented via two-physician protocol, following a hearing with the hospital ethics committee. Given the unusual nature of his case, further measures have been taken to insure patient’s safety while his status as an inpatient.


IMPRESSION & PLAN:

Patient presents today with clean appearance (dressed in hospital gown), distant demeanor, flat/blunted/constricted affect, goal-directed thought processes, decreased memory, decreased concentration, appears alert, bright, and oriented x 2 (time and place). Patient mostly communicated with this writer via head nods or shakes, with the occasional noncommittal monosyllabic answer. Patient is distant, guarded, with poor eye contact, but is mindful of hospital staff and fellow patients.

Patient has unusual physical appearance – silver/gray hair and golden-colored eyes – which appears natural; he is also underweight for his height, though he has gained 3 kg during the course of his hospital stay (input/output net negative). All injuries sustained – scarring, bruising, lacerations to head, neck, shoulders, hands, feet – are consistent with attempted drowning; there were no other physical indications suggestive of unusual corporeal or sexual trauma. Neurological exams performed upon admission were unremarkable for brain tumor, concussion, abnormalities, or any other sort of head trauma.

Patient is positive for some situational anxiety and depression, but there is no evidence of psychosis, severe depression, severe anxiety, or mania. Unclear whether patient attempted to take his own life, or almost drowned as a result of an accident – he offers no memory of the incident or the days/weeks leading up to it. Patient recalls only very basic information about his background, but seems to have no sense of self-identity.

Original physical examination in ER was suggestive of deep water drowning; his body was cold (but not bloated) when he was found down, which is consistent with oceanic temperatures this time of year. It is thought that he was under water for less than 24 hours prior to discovery, as it takes 3-5 days for a body to sink and rise back to the surface at this time of year. He was wearing a full tuxedo and tails, sans shoes, with the tags cut out of all articles of clothing.

Results of extensive cognitive testing have revealed a general wealth of knowledge and highly advanced vocabulary, suggestive of higher education. No abnormalities in the larynx were found during intubation/extubation procedures, leaving us with the impression that he is selectively mute. Because of this, he was given a paper and pencil in order to communicate. Instead of writing, he began to draw musical instruments in some detail, with a particular precision focus on grand pianos, suggesting extensive knowledge of, or experience playing, said instrument.

Impression: Dissociative amnesia, related to recent attempted drowning, r/o PTSD.

Plan:
– admit to Inpatient Psychiatry service
– Nutrition following; appreciate their continued recommendations
– begin art therapy, music therapy, cognitive restructuring therapy; we will go with his strengths and see where he leads us – please allow free use of the music room whenever possible
– no acute indication for medication at this time
– monitor for safety (Level III – Rivers protocol)
– medical decision-making: Drs Higurashi & Mushin (Psychiatry) will assume responsibility from his primary care team (Hospitalist)


STATUS: Full code

Higurashi Kagome, MD, R4-Psychiatry
Mushin Masao, MD, Psychiatry Attending
ELECTRONICALLY SIGNED ON: 07 November 2005