MEDICAL EVALUATION & PROGRESS REPORT

PATIENT NAME: glitchedlad "Eros"

SEX: F

DOB:

DATE OF EVALUATION:

PROVIDER: Automated Outpatient Behavioral Health / Regional Care System

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1. REASON FOR REFERRAL & CHIEF COMPLAINT

Patient presents for mandatory bi-weekly psychiatric re-evaluation following referral by law enforcement. Initial police contact occurred secondary to multiple frantic, non-emergent distress calls made by the patient reporting "unauthorized surveillance and physical stalking." Police on scene noted no evidence of third-party presence or external threat, referring patient for acute psychiatric management and stabilization.

Patient's self-reported complaint:
1 and a half years. 1 and a half years and he gets to roam a free man while i continue to cower.

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2. DIAGNOSIS & CLINICAL PRESENTATION

• Primary Diagnosis: Post-Traumatic Stress Disorder (PTSD), Chronic / Complex.
• Secondary Observations: Severe Persecutory Delusions, Secondary Auditory/Visual Hallucinations.

Mental Status Examination:
Patient arrives appearing severely fatigued, hypervigilant, and displaying a flattened affect punctuated by sudden outbursts of agitation. Patient exhibits extreme tactile and visual paranoia, continuously scanning the room and checking peripheral windows. Motor behavior is restless (persistent pacing).

Patient repeatedly attributes their symptoms to "August" (an alleged real-world perpetrator from a prior closed incident). When reminded that no physical evidence or current law enforcement records support an ongoing physical threat, patient becomes hostile and accuse clinical staff of "ignoring [them]."

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3. SYMPTOM RATING & OBSERVED BEHAVIORS

• Hypervigilance & Paranoia: Critical. Patient is rarely seen outside places they are comfortable in.
• Somatic / Visual Distortions: High. Patient reports visual field degradation, "a tall man in a black hat," and unprovoked panic responses to ambient auditory cues.
• Treatment Compliance: Poor. Patient acknowledges irregular administration of prescribed psychotropics, claiming the medication causes "brain fog" and "makes [them] unable to stomach food."

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4. PHARMACOLOGICAL PLAN & CLINICIAN NOTES

Patient’s distress continues to be driven by unresolved fixation on past trauma rather than external stimuli. The patient's assertion that the current dosage is "making them delusional" is consistent with typical non-compliant trauma responses and diagnostic denial.

Adjustments:

1. Haloperidol (Antipsychotic): Increase dosage from to suppress persistent persecutory hallucinations and nocturnal agitation.
2. Discontinuation Notice: Patient warned that failure to comply with daily regimen or continued misuse of emergency services will result in a referral for involuntary inpatient hold.

Clinician Summary: Patient remains fixated on historical trauma, framing routine isolation as an active threat. Symptoms are behavioral and internally generated. Prognosis remains guarded due to persistent patient resistance to chemical stabilization.