PHOTO>><< Back To Home Page <<Brief
History
PHOTO>>
Psych Eval History & Physical Discharge Summary Chemistries CBC CXR UA
Living Will / Medical Treatment Plan EKG Graphic Chart Nursing Admission Assessment
Physician's Orders Progress Notes Nursing Staff Notes Medication Administration Record
Phone Intake COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL
DAVIS HOSPITAL & MEDICAL CENTER
PSYCHIATRIC EVALUATION
PATIENT: Smith, Lydia
Robert A. Weitzel, M.D.
12-21-95
CHIEF COMPLAINT
The patient is unintelligible but is reportedly quite agitated and aggressive.
IDENTIFYING INFORMATION
This is a 90-year-old widowed white female who is admitted from South Davis Hospital in Bountiful, Utah, and had apparently recently been in the Rocky Mountain Care Center.
HISTORY OF PRESENT ILLNESS
The patient had a stroke approximately four weeks ago and was in South Davis Hospital for rehab. In the past two weeks she has become severely agitated, combative, assaultive, and has been spitting and scratching at people and appeared very depressed. The patient was to be transferred to Rocky Mountain Care Center but was too combative and was a high risk potential for falls, agitation, aggression, and AWOL.
MEDICATIONS: Current medications has included Haldol 0.5 mg t.i.d. with 1-2 mg IM as p.r.n., Lasix 40 mg q. a.m., potassium chloride 8 mEq daily, Lanoxin 0.125 mg q. day, Normodyne 200 mg b.i.d., Vasotec 10 mg q. day, and then Tylenol and Serzone 100 mg b.i.d.
PAST PSYCHIATRIC HISTORY
The patient has had no previous psychiatric admissions. No previous psychiatric history of note. After her husband died she had brief psychotherapy.
PAST MEDICAL HISTORY
She had a stroke in November of 1995. Apparently had cholecystectomy this year and she is currently treated for atrial fibrillation, congestive heart failure, and hypertension. Apparently no seizures or head trauma.
Continued…….
PSYCHIATRIC EVALUATION
Lydia Smith
Page 2 …PE
Robert A. Weitzel, M.D.
SOCIAL HISTORY
She has a high school diploma and some college. She worked in real estate and had been a housewife. She is L.D.S. She is a nonsmoker, nondrinker.
FAMILY HISTORY
Negative for psychiatric disorder.
PATIENT STRENGTHS
Supportive family.
PATIENT LIMITATIONS
Aphasia, dementia, depression.
MENTAL STATUS EXAMINATION
In general this is an elderly appearing white female, who is fairly nonresponsive. Speech consists of guttural unintelligible ejaculations. Mood is fairly dysphoric. Affect is congruent. Thought process is difficult to ascertain. Thought content is difficult to ascertain. She apparently hears and sees, IQ seems grossly impaired. Calculations, memory, abstractions, fund-of-knowledge were all untestable. Insight was poor, judgement was poor.
DIAGNOSIS
Axis I: Major depression with psychotic features.
Axis II: Defer.
Axis III: Status post cerebrovascular accident, congestive heart failure, hypertension.
Axis IV: Four.
Axis V: Twenty.
DISCUSSION & RECOMMENDATIONS
We will start her on Cipro for an apparent urinary tract infection. She has been started on Haldol and Serzone will be continued. Tonight I am going to increase her Risperdol as she has been somewhat combative and difficult today. I will give her an aspirin per day against multi-infarct dementia and she will get a full medical work-up.
Continued……… PSYCHIATRIC EVALUATION
Lydia Smith
Page 3 …PE
Robert A. Weitzel, M.D.
ESTIMATED LENGTH OF HOSPITALIZATION
Three weeks.
DISCHARGE CRITERIA
No aggressiveness, improved mood.
DISCHARGE PLAN
Back to Rocky Mountain Care Center.
(Signed) Robert A. Weitzel, M.D.
RAW/lw
D: 12/21/95 22:38
T: 12/22/95 11:35
Job# 2577
Psych Eval History & Physical Discharge Summary
Living Will / Medical Treatment Plan