May 14, 1970: Psychiatric report re: Helena Stoeckley's
April 17, 1970 hospital admission
Note: Translation of the document following scanned pages
Note: Translation of the above document as I read it to be
FINAL DIAGNOSIS: Narcotic addiction in a schizoid personality
DISPOSITION The patient is to return on an outpatient basis to Womack Army Hospital psychiatrist in Fayetteville.
HISTORY OF THE PATIENT ILLNESS: This patient was reportedly well until approximately a year ago when she began using narcotics along with other high school classmates. Since that time she has been increasing her drug schedules and taking approximately everything available, including heroin, opium, LSD Cocaine, (unable to read) barbiturates and has been widely known as a narcotics dealer. Around February, 1970, she began feeling depressed, explosive and moved out of her home because her addiction was getting too much for her to cover up from her parents who did not know of this. At that time she began taking large doses heroin, as many as 8-9 times a day, and she reports that over the past 3-4 weeks she has tapered herself to the point that she takes only 2 cc of heroin a day.
The patient also began having pain in her right side approximately two days prior to admission. She saw a Womack army doctor who told her that she may have had hepatitis and recommended North Carolina Memorial Hospital Psychiatric admission. The patient also reports having "nooicy" dreams waking up screaming in the past 2-3 days.
Past medical history reveals the usual childhood diseases without sequelae. Jaundice at birth without sequelae. Pneumonia at six years. T&A at 8 years of age. Broke her left arm sledding approximately three years ago without sequelae.
Review of symptoms: No known allergies. The patient reports dark urine for the last week.
Family and social history: Her father is a retired army colonel living in Fayetteville.
PHYSICAL EXAMINATION: Entirely within normal limits except for a slight tenderness in the right upper quadrant and in the left upper quadrant. There were bilateral needle marks in the antecubital fossa and on the back of the left hand. Ecchymoses were noted about these areas. Genitorectal examination was deferred at the patient's request. This was reportedly within normal limits two weeks ago.
LABORATORY DATA: Glucose 85; calcium 7.4; phosphorus 2.0; total protein 3.3; albumin 4.0; SGOT 53; SGPT 90; LDH 440; alkaline phosphatase 5.8; cholesterol 151; direct bilirubin .4, total bilirubin 1.0; bromide level (unable to read). After ten days of hospitalization glucose level was 98; calcium 9.3; phosphorus 6.7; total protein t.0; albumin 3.8; SGOT 35; SGPT 48; LDH 345; alkaline phosphatase 5.8; direct bilirubin.5; total biliburin .0.
Urinalysis was within normal limits and was negative for bile.
Chest film negative
HOSPITAL COURSE: The patient was placed on a methadone withdrawal schedule which was completed after 10 days without difficulty. The patient remained extremely occlusive throughout her hospitalization denying that she had any psychological factors which may have contributed to her addiction. She was seen as a schizoid personality, extremely mistrustful. No trusting relationships were established during her hospital course. The patient described her experiences while taking drugs and reported that she intended to continue taking them in the future. Her activities seemed to be one of rebellion against all including her family, and affect seemed generally depressed even at the time of discharge. She denied suicidal or homicidal thoughts.
Mental status examination reveals a neat white female appearing her age without distress. She was oriented to person and place but thought that the day was April 26 when it was actually April 17. (First two words unable to read) within normal limits. (First two words unable to read) were fair. Six numbers frequently, five backward. She was an intelligent, well-informed lady. She denied hallucinations, delusions and ideas of reference except that two days ago she felt "outside" herself and at times felt that someone was standing over her with a knife and was going to kill her but then went away. The patient stated emphatically "I am perfectly normal" and presented herself as one bragging about her character as a narcotic addict using most of the jargon of the narcotic addict. The prognosis of this patient remains poor.
The patient had a medical consultation for the possibility of hepatitis. At that time she was laced on isolation on admission. This was discontinued after five days, she apparently did quite well without evidence of hepatitis
James S. Howard, III, M. D.