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Assessment
(Presbyterian Hospital - April 27, 1992)

HISTORY:
CC: Paranoid behavior.

HPI: This 26 year old white female was seen in this ED yesterday afternoon with acute onset of paranoid behavior.  This had begun yesterday morning with the pt. running around the house, ringing bells, and looking behind light switches, books, etc.   She felt the house had been "bugged" and she was looking for these bugs or wire taps.  She had not slept very much the previous night.  Her behavior was bizarre and somewhat illogical per her husband, and he brought her to the ED.  He noted she had had some intimations of similar behavior previously, i.e., a feeling that the parents of the children that she teaches in Sunday school had gotten together and decided to make the children act poorly in order to annoy her.  Dr. Rody's exam showed basically a normal neurologic exam at that time.  Concentration was poor.   Attention was poor, and ability for abstract thought was impaired.  Lab evaluation was unremarkable.  The pt. was felt to be suffering a probable acute psychotic break manifest by paranoid schizophrenia, and was discussed with Dr. young, covering for her reg. Pacificare phys., Dr. Levy, with Dr. Smith, the Psychiatrist on call for the OCC, and with Pacificare benefits people who informed Dr. Rody that she was not covered for inpatient psychiatric care.  She was transferred to the Crisis Center, and from there apparently on an EOD to Central State Hosp.  Dr. Morgan, covering for Dr. Levy, and myself were both contacted today by the psychiatrist on duty today at Central State Hosp.  He noted the pt. was confused, paranoid with word salad, and other typical findings of
schizophrenia.  He was concerned, however, that she seemed to have a somewhat wide-braced gait at that time, fell backward easily, and was somewhat hyperreflexic, left greater than right.  Her cerebeller testing, he felt, was not normal as well.   He was concerned that she might require CT scanning.  He was willing to have her evaluated from a neurologic standpoint there, but her parents apparently were unwilling to leave her there,  and she is sent back to the ED for repeat evaluation and CT scanning if felt appropriate.  The pt. states she feels well today.  She states, yesterday, she was sad, but today, she is happy because she has changed her attitude.  She notes she does not remember much of yesterday because her husband and other people were giving her sedatives in order to change her behavior, and she had been taking these because "they seemed like they knew what they were talking about."   She denies any pain or other symptom of illness.  Per her and her husband, she has had no recent fevers, chills, rhinorrhea, earache, throat soreness, cough, vomiting, diarrhea.  She has had some intermittent H/A's which began when she got a new set of eyeglasses which she states have been relieved by her husband gently stroking her forehead.  She had a period that was normal in timing, duration and amt. ending 3-4 days ago, and has not had sex since her period.  She normally takes BCP's.  She has no known med. allergies.

ROS: As above.

PH: As above.

FH:

SH:

EXAMINATION:
VS on adm. - T 98.2 orally, P 112, R 16, BP 168/80.  This is a WDWN, alert, very cooperative, white female currently in no apparent distress.  TMs are benign.   Pupils are midposition, equal, round and reactive to light.  EOM is full.   Fundi are benign with discs sharp.  Nose is clear.  Dropharynx is benign.   Neck is supple and w/o adenopathy.  Heart shows a RRR.  Lungs are clear to auscultation throughout.  Abdomen shows normoactive bowel sounds, and is soft and nontender.  Cranial nerves 2-12 are grossly intact and symmetric.  Sensorimotor function is, likewise, grossly intact and symmetric on exam.  DTRs are 2-4+.  At this time, I really do not appreciate any asymmetry, but pt. is diffusely hyperreflexic.   The is no abnormal plantar response.  The pt. does fall back slightly when standing up from the carrier, but catches herself when I do Romberg testing, actually this is normal, although she does not cooperate very well in terms of keeping her eyes closed.   Function is only fair on cerebellar exam, specifically finger-to-nose, heel-to-shin, and alternating hands.  I do not appreciate any significant dysymmetry.   Gait is slow and is rather deliberate, as is her speech, and other action, but I do not really
appreciate frank ataxia at this time.

MEDICAL DECISION MAKING:
CT scan of the head is done with and w/o infusion.  Per Dr. Vanhooser, this reveals no visible intracranial abnormalities.

At this point, I have discussed with pt.'s husband, father, mother, and other members of the family LP.  I have discussed the indications for, benefits of, and risks of this procedure, the latter including but not limited to bleeding, infection, damage to spinal nerves.  They do not wish her to undergo LP at this time (I do not feel pt. is currently competent to make this decision for herself).  I have explained to them the risks of untreated subarachnoid hemorrhage or meningitis, including brain damage and death, and they understand to my satisfaction.

The pt. has been discussed with Dr. Morgan, very extensively discussed with the family, and again discussed with Dr. Morgan.  She will be admitted to Presbyterian Hosp. for observation and further neurologic evaluation as indicated.  She will be admitted under suicide precautions, and I have asked that a family member be available to stay with her in the room 24 hrs. a day, and this is agreeable to them as well.   Admitting orders are written by me per Dr. Morgan's preferences following consultation with him.  See orders.

ASSESSMENT: Acute psychotic episode; R/O toxic/metabolic/structural pathology.

DMA: skv DAVID M. ABERCROMBIE, M.D.
DD: 4-27-92  1837