NYU Medical Grand Rounds Clinical Vignette Catherine Constable, M.D. PGY2 1/10/2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

36-year-old male artist and torture survivor with the near inability to use his hands to paint for over ten years. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

This is a 36-year-old Tibetan male who initially presented to the Bellevue/NYU Program for Survivors of Torture in 2003, shortly after immigrating to the United States. As a teenager in Tibet, he was arrested and tortured in prison for painting traditional Tibetan images banned by the Chinese government. During his months of detention, he endured beatings, electrocution, and hanging by his handcuffed wrists. Lastly, as punishment for his poetry-writing, his attackers thrust his hands into a coal-burning oven, telling him, “you’re not doing anything useful with your hands.” History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Burn scars left him unable to hold a pencil or paintbrush without pain. Symptoms of PTSD included nightmares, insomnia, hypervigilance, and debilitating flashbacks every time he tried to hold a pencil or paintbrush. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Social History: Born in Tibet. As a child, he studied art at a Tibetan monastery. In his adolescence, he was commissioned by the Chinese government to create state-sanctioned art. After he began creating traditional Tibetan art as a means of protest, he was arrested. He fled over the Himalayas with his hands still in bandages into Nepal, and ultimately arrived in the U.S. in U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination Left hand flexion contracture bands of 2 nd and 3 rd digits and radial side of thumb; right hand flexion bands from thumb to 3 rd and 4 th digits. Well-healed burn scars to palms bilaterally. Flexion intact, extension of fingers limited due to contractures. Shoulders with decreased range of motion bilaterally, left more than right. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Photo credit: Jonathan R. Tan U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Physical Examination

Pain management Management of severe symptoms of depression and PTSD with individual and group counseling with other Tibetan survivors of torture, as well as with medication 4/1/2004: Z-plasty of right palm for release of contractures, which enabled him to hold a paintbrush again Physical therapy for shoulder pain with improvement in his range of motion Hospital Course/Outpatient Follow-up U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Photo credit: Jonathan R. Tan

The Present U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Photo credit: Jonathan R. Tan