Jolynne's Web Site - Assessment (Brain P Levy, MD

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Assessment
(Brian P Levy, MD - April 27, 1992)

PATIENT: Burns, Jolynne
DATE: 4-27/4-29-92
PHYSICIAN: Levy

DISCHARGE SUMMARY

ADMISSION DIAGNOSIS:
Altered metal status with psychotic behavior, uncertain etiology.

DISCHARGE DIAGNOSIS:
Acute psychotic break - depression versus schizophrenia

CONSULTANTS:
Neurology consultation per Dr. Robert Dow
Psychiatry consultation per Dr. E. Michael Smith

HISTORY:
The patient was admitted from the Emergency Department for evaluation of her altered mental status. She has been seen in the Emergency Department at Presbyterian Hospital on April 26, 1992, and sent to the crisis center. She was then sent on an EOD to Griffin Memorial Hospital in Norman. The physician at Griffin Memorial was concerned about her gait and thought that her reflexes were increased. She was sent back to the Emergency Department and admitted for further evaluation and treatment. (Please see the copy of her admission history for details.)

PHYSICAL EXAMINATION:
The patient was a well-developed, well-nourished, somewhat overweight, white female who was in no acute distress. Blood pressure was 168/80, pulse 112, respirations 16 and the patient was afebrile. Pupils are equal, round and reactive to light. Fundi were benign. Her extraocular movements are intact. Neck was supple without lymphadenopathy or thyromegaly. Lungs were clear. Heart had a regular rate and rhythm without murmur, click or gallop. Abdomen was benign. Neurologic showed cranial nerves II-XII were grossly intact and symmetrical. Her sensory function appeared normal. Her reflexes were brick but symmetrical. Her gait and speech are slow. She displays psychotic thinking at times.

LABORATORY AND RADIOLOGY STUDIES:
Her white count was 9.7, hemoglobin was 13.9 and hematocrit was 41.4. Chem-7 was normal except for BUN of 5. Sedimentation rate was 10. ANA was negative. A CT scan of her head was done and showed no significant abnormalities.

HOSPITAL COURSE:
The patient was admitted for evaluation of an acute change in her mental status. She was thought to be experiencing a psychotic episode. Dr. Dow saw her for neurology consultation. MRI of her head was done and showed no significant abnormalities. Her problem was thought to be of psychiatric origin and Dr. Michael Smith saw her in consultation. It was his thought that she was most likely experiencing depression and showing psychotic features. She was started on nortriptyline, 50 milligrams po at hs and Haldol, two milligrams po bid. An EEG had been done and was normal.

With her family's understanding and consent, she was transferred to the psychiatric unit at Mercy Health Center on the afternoon of April 29, 1992.

DISCHARGE DISPOSITION:
The patient was taken by her family to the psychiatric unit at Mercy on the afternoon of April 29, 1992.

B. P. Levy, M.D.
D,T 05-23/05-27-92/sh