An Enraged 36-Year-Old Man With Razorblade Slashes on His Arms

Jeffrey S. Forrest, MD; Alexander B. Shortridge

Disclosures

September 18, 2020

Physical Examination and Workup

The patient is 5 ft 7 in (1.7 m) and weighs 160 lb (72.57 kg). His blood pressure is 138/94 mm Hg, and his temperature is 98.3°F (36.8°C). His oxygen saturation is 97% on room air.

The patient appears disheveled and agitated, has tense posture, and exhibits increased psychomotor activity. An ecchymosis is noted on the right side of his forehead. Scarring and recent superficial cutting wounds are present on both forearms. An example of wounds similar to the patient's is shown in the figure below.

Figure 1.

The patient's heart rate is tachycardic at 110 beats/min. No murmurs, rubs, or gallops are audible. His heart rhythm is regular. His respiration rate is elevated at 18 breaths/min. His lungs are clear to auscultation bilaterally. His abdomen is nontender and tympanitic to percussion, with normal bowel sounds. He does not display facial droop, and his cranial nerves are otherwise intact.

During the mental status examination, the patient is alert and oriented to name, location, date, and time. He appears depressed and anxious and exhibits some motor overflow. His speech widely varies in volume, rhythm, and tone and fluctuates throughout the interview. His recall is good when measured for immediate, recent, and distant memory.

The patient's thought process is occasionally tangential, but he is able to be redirected. His thought content is dominated by current stressors. He keeps repeating, "It's not fair." As noted in an earlier examination, the patient reports depression and a significant history of self-mutilating behaviors. When asked about his mood, he says, "I feel empty." His affect is labile. He appears capable of attending to the interview but does not always cooperate. His insight is limited to poor, as he appears to downplay the significance of his behaviors. His judgment is similarly poor. The patient denies auditory and visual hallucinations.

An ECG shows a heart rate of 110 beats/min, but the findings are otherwise normal. A CT scan of the head without contrast reveals normal findings, with no evidence of a cerebrovascular accident, mass lesion, or bleeding. Urine toxicology screen results are negative. Urinalysis findings are within normal limits. His complete blood cell count, comprehensive metabolic profile, and thyroid-stimulating hormone levels are all within reference-range values.

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