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DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

PATIENT: CRANE, MARY

DATE OF CONSULTATION: 12/29/95

ATTENDING PHYSICIAN:

CONSULTING PHYSICIAN: DAVID DIENHART, M.D.

 

REASON FOR CONSULTATION

Medical evaluation on admission to the Geropsych Unit, provisional psychosis.

HPI

Mrs. Crane is a 72 year-old Caucasian female admitted now to the Geropsychiatric Unit with history of recent aggressiveness, verbally abusive behavior, increased anxiety, agitation.

PAST MEDICAL HISTORY

GENERAL:

1. Right cerebrovascular accident, 11/90, right thalamic region resulting in left hemiparesis. She is currently limited to the wheelchair and bed activities with significant left partial paralysis. She is also debilitated by chronic low back pain with history or prior low back surgery.

1.      Hypertension.

2.      Also remarkable for a history of chronic hyponatremia, in the 130 to 135 range, occasionally in the low 120 to 125 range, unclear etiology but by history has been evaluated in the past by her primary physician.

3.      History of peptic ulcer disease.

4.      Remote history of meningitis.

5.      History of transient ischemic attacks.

Today Ms. Crane has no complaints and she denies any shortness of breath and chest pain; she denies any significant pain. She has been placed on a Duragesic patch as well as Relafen for her low back pain with resultant marked improvement.

CONTINUED….

REPORT OF CONSULTATION

CRANE, MARY

PAGE 2…

DAVID DIENHART, M.D.

SURGERIES: 1. Partial gastrectomy vagotomy. 2. Lumbar disc surgery.

MEDICATIONS: Tylenol one to two p.o. Q 4hrs pain, Mylanta 30 cc p.o. Q 4 hours dyspepsia, Milk of Magnesia 30 cc. p.o. Q h.s. PRN constipation, Zantac 150 mg. P.o. BID, Lopressor 100 mg. P.o. BID, Glucotrol 5 mg. P.o. Q a.m., Accuchecks a.c. and h.s. x 3 days, Dyazide one tablet p.o. QOD, Artificial Tears Q 3 hrs PRN for dry eyes, Carafate one gram BID, Lasix 80 mg. QOD, ferrous sulfate 325 mg. P.o. daily, Metamucil one tablespoon TID, Risperdol 1 mg. Q a.m. at 5 p.m., Serzone 50 mg. P.o. BID for two days and then increased to 100 mg. P.o. BID, Trazodone 100 mg. P.o. Q h.s., Relafen 1000 mg. Given on 12/28/95 and Duragesic 50 ug patch Q 3 days, K-Dur 20 mEq BID.

ALLERGIES: PENICILLIN, CATAPRES, DILANTIN, TAGAMET, ASPIRIN, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS, MEPROBAM.

SH: The patient has three children. The patient does not smoke or drink alcohol.

PHYSICAL EXAMINATION

GENERAL: The patient is a supine, elderly female, oriented to person, place, hospital site, Salt Lake City, year 1995, time of year (just after Christmas). The patient cannot recall the President of the United States.

VITAL SIGNS: Vital signs on admission show blood pressure 130/80, weight 148 pounds, temperature 98.1, respiratory rate 20 per minute, pulse 80.

HEENT: PERRLA. Conjunctiva are pink. Right TM is obscured by cerumen, the left is visualized and is dull. Nasal mucosa is pink, throat is clear. The patient has no teeth in her uppers and dentition is in poor repair in the lowers.

NECK: Supple. No adenopathy.

CHEST: Axilla show no adenopathy. Breasts are pendulous with no masses palpable. Lungs are clear without wheeze. There are minimal basilar rales are present.

HEART: Regular.

ABDOMEN: Soft, nontender with no hepatomegaly.

EXTREMITIES: No edema.

CONTINUED…

REPORT OF CONSULTATION

CRANE, MARY

PAGE 3

DAVID DIENHART, M.D.

DIAGNOSTIC STUDIES

EKG is normal sinus rhythm at 62 beats per minute, no acute ST T-wave changes.

Chest x-ray PA and lateral: enlarged cardiac silhouette, clear lung fields, density in the right shoulder region of uncertain significance, may represent old trauma but could not exclude a degenerative or metastatic process per Dr. Dedrickson.

Lab: sodium 131, potassium 3.3, chloride 99, CO2 30, anion gap is 2, glucose is 111, BUN 35, creatinine 1.4, calcium 9.1, uric acid 6.8, cholesterol 189, triglyceride 163, total protein 5.6, albumin 2.9, total bilirubin 0.4, alkaline phosphatase 112, GGT 16, ALT 12, AST 16, LDH 72, phosphorous 2.9, magnesium 2.2, iron 39, T3 31.6, T4 6.3, T7 1.99, pending TSA.

WBCs 9,400, hematocrit 35.7, MCV 82.3, platelet count 418,000, RPR is nonreactive.

IMPRESSION

  1. Anemia, mild.
  2. Hyponatremia.
  3. Hypokalemia.
  4. Mild metabolic alkalosis.
  5. Hypoalbuminemia.
  6. Low serum iron, may represent anemia of chronic disease.
  7. History, right cerebrovascular accident, right thalamic region, 11/90, with residual left hemiparalysis.
  8. Chronic low back pain, secondary to disc disease.
  9. Hypertension.
  10. History of peptic ulcer disease, status post partial gastrectomy vagotomy.
  11. Right shoulder density, unclear etiology.
  12. Cardiac silhouette enlargement by portable AP chest x-ray, possibly secondary to hypertensive cardiovascular disease, unknown, left ventricular function.

RECOMMENDATIONS

  1. Agree with adequate pain control with nonsteroidal anti-inflammatory drugs and Duragesic, however, it has listed as allergy to nonsteroidal anti-inflammatory drugs on a past medication list. This may be from her past history of peptic ulcer

CONTINUED…

REPORT OF CONSULTATION

CRANE, MARY

PAGE 4

DAVID DIENHART, M.D.

          disease. If she has had a vagotomy and partial gastrectomy, this may no longer be problematic.

  1. Her laboratory suggests a mild volume depletion secondary to diuresis. Her low sodium may be a combination of this diuresis and a component of psychogenic water drinking although this evaluation is not clear.
  2. If  her sodium becomes problematic would suggest restriction of fluid to 1200 to 1400 cc per day.
  3. For anti-hypertensive control with her current well controlled blood pressures, would consider discontinuance of Dyazide which will also aide in diminishing problems with hypokalemia, and decreased Lasix to a daily 20-40 mg. dose. Her potassium titration may need to be lessened with these changes. If she needs further anti-hypertensive control, would consider a low dose of an angiotensin converting enzyme inhibitor such as Zestril 10 mg. daily in addition to her current dose of Lopressor.
  4. With consideration of possible mental status changes with H2 blockers, would consider stopping Zantac and the utilization of Carafate only. If needed, Carafate could be increased to a TID or QID dosage.
  5. Would consider right shoulder films to evaluate right shoulder density see o chest x-ray.
  6. Etiology for hypoalbuminemia is unclear, may represent poor nutritional intake. If any destructive lesions are seen on plain shoulder radiograph, would perform serum protein electrophoresis as well as other screening bone survey, i.e., of the pelvis and skull, to rule out any lytic disease consistent with myeloma.

Thank you for asking me to evaluate Ms. Crane.

 

(Signed)

David Dienhart, M.D.

DD/re

D: 12/29/95 14:01

T: 12/30/95 16:32

JOB #3712

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

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