History

Pre-1992
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Assessment
(Presbyterian Hospital - April 26, 1992)

HISTORY:
CC: Possible paranoid reaction.

HPI: This 26 year old white female was running around her house turning on lights this morning.  She thought her house was bugged by her and her husbands family members.  Her husband reports that she was looking in bells and books etc. for these bugs or taps.  This has never happened before.   She has no recent head trauma or fever.  She did not get much sleep last night, she reports.  She denies hearing voices.  There is some question of visual hallucinations.  She thought she saw her pastor go by and her husband didn't and thought she saw her parents car and her husband didn't.  She has no suicidal or homicidal ideations.  No history of psychiatric problems or visits to a psychiatrist.   Her husband was concerned about some paranoid tendencies before.  She keeps kids at a church on Mondays and had the feeling that all the kids parents got together and decided to have the kids act bad this past Monday, just to see how she handled the situation.  No other complaints.

ROS: Otherwise negative.
PMH: Some question of borderline hypoglycemia.
PSH: She had a breast reduction.
She has no known drug allergies.  Medications - Birth control pills.
Last Tetanus - 2 years ago.  LMP: At present.
FH & SH: Not reviewed.

EXAMINATION:
On exam she is alert, oriented in no acute distress.  Does not look septic or toxic.   Vital signs are Temp. 99.5, Pulse 84, Resp. 14, BP 136/70.  HEENT, normocephalic atraumatic.  Neck supple, no meningneal signs.  Neurologically normal level of mentation as mentioned.  Cranial nerves 2 through 12 are intact.   Motor 5/5 Plus 4, sensory exams are intact and symmetric.  She had a normal gait.  No trunkal ataxia.  Mental status exam, again she denied any visual or auditory hallucinations.  Her concentration was not normal.  Her intelligence appeared to be a bit below normal.  She demonstrated an inability to think abstractly.  No other significant physical findings were initially noted.  Her tilt test was negative.   Her WBC count was 9.7, Hbg 13.9.  Hct. 41.4, Platelet count 201, 72 Segs, 21 Lymphs, no Bands.  Her Calcium was 9.7, Phos. 3.1, Mag. 2.1, Sodium 138, Potassium 4.5, Chloride 104, Bicarb 26, BUN 5, Creatinine 1.1, Glucose 109.

I discussed the case with Dr. Young, who was covering for the patient's regular Pacificare Physician Dr. Brian Levy.  I discussed the case with Dr Smith the psychiatrist on call at the OCC.  I discussed the case with Chris Merrill with Pacificare who informed me that this patient does not have in-patient psychiatric benefits and therefore would have to be referred to Crisis Center.   I discussed the case with the triage person at the Crisis Center and with Dr. Keller at the Crisis Center, who agreed to accept the patient in transfer to the Crisis Center.

ASSESSMENT: 1)Acute Psychosis, R/O Paranoid Schizophrenia

PLAN: To the Crisis Center for Psychiatric Evaluation, Accepted by Dr. Keller.  Transfer papers will be filled out and a copy of this dictated report will be sent with the patient and we will send the patient by private vehicle with her husband to the Crisis Center of Psychiatric Evaluation.

Br/pnb Brent Rody, M.D.
4-26-92
TC:4-26-92