1. NYU Medicine Grand Rounds Clinical Vignette Joshua Strauss, MD PGY2 February 2, 2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 31 year old woman who presented with a chief complaint of depression and insomnia for the past six months. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS The patient’s history began when she was born in West Africa in 1980. At age six, the patient’s father passed away and from that time on, her extended family harassed and attacked her, her mother, and her sister for not being sufficiently traditional, and for trying to flee their home.

4. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS When she was 7 years old, she was forced to undergo female genital mutilation. Since this time, the patient has endorsed chronic, throbbing, external pelvic pain, which worsens with walking. She and her family subsequently tried to flee West Africa, and were often beaten and burned as punishment.

5. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS In 2003 she escaped from her home country and moved to Denver. On arrival to the US, she initially felt safe and reassured, later marrying, after which she has endorsed chronic dyspareunia.

6. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS One year before presentation she began trying to reconnect with family members in her home country. After hearing distressing news about the mistreatment of her mother, she became increasingly anxious. She developed insomnia, terrifying nightmares with screaming out, poor appetite, sad mood, low energy, apathy towards her work and memory difficulties.

7. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS One month before presentation she moved to New York for better access to care, and presented to Bellevue in March, 2009.

8. Additional History Past Medical History: None Social History: Denies tobacco use, alcohol use and drug use. Lives with friends in the Bronx. Her husband lives in Denver. She has no children. She previously worked as a home attendant in Denver. Family History: Mother: Depression Father: Died in 1986 - medical history unknown Sister: Disappeared - medical history unknown Allergies: No known drug allergies Medications: None U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Physical Examination General: Well groomed, soft spoken, flat affect. Vital Signs: T:98.6 BP:125/80 HR: 65 RR: 14 and O2 sat: 99%RA Extremities: Small scars on hands and wrists bilaterally. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Physical Examination Pelvic: Left labia minora excised to prepuce. Right labia minora partially excised only posteriorly, with flag-like remnant of anterior labia minora, tender to touch. Scar tissue on anterior wall of prepuce, tender to touch. Clitoris intact. Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Laboratory Findings All laboratory values were within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Post-traumatic stress disorder due to. Depression Chronic pelvic pain /dyspareunia due to Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. After presenting to Bellevue in 2009, she began receiving medical, mental health, social, and legal services through the Bellevue/NYU Program for survivors of torture. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. The patient has followed closely with the mental health clinic: –She started individual psychotherapy, and was initiated on sertraline 50mg daily, and quetiapine 25 mg daily with some relief of her symptoms of depression and anxiety. –She joined a weekly group therapy session in French with other survivors of torture. She stated that this therapy helped her to know that others felt like she does: “Before, I thought I was not normal,” she said. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. The patient was also referred to Gynecology for chronic pelvic pain and dyspareunia: –She was initially given lidocaine gel for pain with minimal relief. She would later undergo right labioplasty, which resulted in significant relief of her pelvic pain. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Since her initial visit, the patient has also connected with a social worker and a legal liaison from the survivors of torture clinic, who are currently working on granting the patient asylum. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Post-traumatic stress disorder amenable to pyschotropics and psychotherapy Depression Pelvic pain due to scar tissue formation, improved after labioplasty Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS