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DAVIS HOSPITAL & MEDICAL CENTER
PSYCHIATRIC EVALUATION
PATIENT: Crane, Mary
Robert A. Weitzel, M.D.
12/28/95
CHIEF COMPLAINT
"Put me to bed, I just want to go to bed."
IDENTIFYING INFORMATION
This is a 72 year-old widowed white female who had recently been at Sandy Regional.
HISTORY
This patient had been on the Alzheimer’s unit after having had a stroke in 1989. She has been extremely agitated, spitting, aggressive, drinking out of the toilet, hitting, verbally abusive, running into others with her wheelchair and screaming. She sticks her fingers down her throat to throw-up. She is very anxious, agitated, and complains of low back pain and headaches. She has been transferred to our unit for treatment of her depression and psychotic features.
PAST PSYCHIATRIC HISTORY
Apparently she has had a long history of previous depression. Currently she is on no antidepressants. She also has a history of apparent psychogenic polydypsia with hyponatremia, down to 108 and there were seizures associated with this. I have no clear history as to her previous psychiatric medications or antidepressants. I do have a report that she had been on Thorazine for some time and she does exhibit some signs of tardy dyskinesia.
PAST MEDICAL HISTORY
She had a stroke in 1989, has had a herniated disc in 1984, and poor control of her pain since then. She had a gastrectomy in the 1980’s, secondary to history of GI bleeds. She has been treated for this with Zantac and Carafate. As noted above, she has had chronic low sodium because of polydypsia.
Continued…..
PSYCHIATRIC EVALUATION
Mary Crane
Page 2 … PE
Robert A. Weitzel, M.D.
MEDICATIONS: Current medications include Zantac 150 mg b.i.d., Lopressor 100 g b.i.d., Glucotrol 5 mg q. a.m., Hyphen one tablet p.o. q. 4. hours p.r.n. pain, Dyazide one p.o. q.o.d., Lasix 30 mg p.o. q.o.d. (Dyazide and Lasix on alternate days), artificial tears, Carafate, Metamucil, ferrous sulfate.
SOCIAL HISTORY
As noted above, she is a widow, she has been treated in the alzheimer’s unit for some time. She had worked as an L.P.N. She has one year of college in the L.P.N. program. She worked at Salt Lake County Hospital and then in an extended care facility. She stopped working in 1976. She is L.D.S. She apparently does not smoke or drink.
FAMILY HISTORY
I have no history available for family history.
PATIENT STRENGTHS
She is verbal.
PATIENT LIMITATIONS
Dementia, chronic depression.
MENTAL STATUS EXAMINATION
In general the patient is an elderly appearing female in a wheelchair. Speech is normal in rate, rhythm, fluency, mood is quite dysphoric. Affect slightly labile. Thought process is slightly loose and there is some blocking thought content, revolves around getting into bed and relieving the pressure on her back. Hearing is fair, sight is fair. Cognition, IQ seems somewhat grossly depressed secondary to dementia. Calculations were not attempted. Memory is intact to some remote but very poor to immediate recall. She only remembered one of three objects with prompting. Fund of knowledge not tested, insight is poor, judgement is poor.
Continued…..
PSYCHIATRIC EVALUATION
Mary Crane
Page 3 … PE
Robert A. Weitzel, M.D.
DIAGNOSIS
Axis I: Major depression with psychotic features.
Axis II: Defer.
Axis III: DVA probable MID, history of BI bleeds, hypertension, and adult onset diabetes.
Axis IV: Three.
Axis V: Twenty-two.
DISCUSSION & RECOMMENDATIONS
THE PATIENT WAS STARTED ON Sersone and Risperdol to treat her depression and psychotic features. She will also be on Trazodone for sleep. I will give her Duragesic patch in a low-dose for her pain. Given her dementia and general medication condition I have very little fear of negative consequences of any addiction. We will set firm limits on her negative and aggressive behaviors and hope that in two or three weeks she will improve.
ESTIMATED LENGTH OF HOSPITALIZATION
Two to three weeks.
DISCHARGE CRITERIA
No agitation improved mood, no aggressiveness.
DISCHARGE PLAN
Back to her previous center.
(Signed)
Robert A. Weitzel, M.D.
RAW/
D: 12/28/95 19:40
T: 12/29/95 10:15
Job# 3577
Psych Eval History & Physical Discharge Summary Chemistries CBC's CXR's
Living Will / Medical Treatment Plan EKG Graphic Chart Nursing Admission Assessment
Physician's Orders Progress Notes Nursing Staff Notes Medication Administration Record
