Patient Name: Decker Jenkins
Date of Birth: April 8, 1971
Original Complaint (physical): Headaches and some slight blurred vision
Original Complaint (psychological): Insomnia, visions.
Brief Summary: I consider Mr. Decker Jenkins a suicide risk. Decker was abused as a child and developed an imaginary companion named Simian. Simian talks to Decker all the time and tells Decker what to do. Decker realizes that without Simian he might have a normal life, a girlfriend, and a steady job, but he is very dependent on Simian. Using therapy and drugs, I'm trying to keep Decker's schizophrenia under control. Total number of sessions: 11.
Brief Impression: Decker has been profoundly abused as a child and now is an angry, young man with psychotic symptoms--predominantly expressed as auditory hallucinations (an old man named Simian) which form a running commentary in his mind.
Tentative Diagnosis: Active phase Criterion A2 Schizophrenia of Undifferentiated Type. Possible suicide risk. Decker is resistant to taking medications and long-acting intramuscular injections or involuntary commitment must be considered if Decker is non-compliant.
Current Medications: Prescribed risperidone, 6 mg. daily + Vitamin E, 1200 IU on October 14, 1997. Stopped taking medication in June. Prescribed risperidone, 6 mg. daily + Vitamin E, 1200 IU on April 18, 1997 for 4 week trial.