DAVIS HOSPITAL & MEDICAL CENTER

COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL

PSYCHIATRIC EVALUATION

PATIENT: Anderson, ELLEN

ROBERT WEITZEL, M.D.

12/29/95

IDENTIFYING INFORMATION

This is a 91 year old widowed white female who is a resident at Pioneer Care Center in Brigham City.

CHIEF COMPLAINT

The patient is unable to verbalize. The family reports that she has been demented for some time and has recently been severely anxious.

HISTORY

The patient has had the diagnosis of dementia for 4 years. She has been suffering severe anxiety attacks of late. She had a severe hip fracture in June, 1995, and has been in rehab for this. She has been at Pioneer Care Center for the past three weeks. There she has been severely anxious, calling out for her children. She has been treated there with Xanax by Dr. Harrow without much help. She is fairly demented, mumbling, can’t finish sentences, chants to herself, and is not consolable by her family. She did have a severe depression following the hip surgery. She also had a UTI on December 1^st.

PAST PSYCHIATRIC HISTORY

There has been no treatment for any past psychiatric problems.

MEDICATIONS: Amitriptyline 25 mg. Q h.s., Lasix 40 mg. Q day, potassium chloride 20 mEq Q day, Nitrostat 0.4 mg. Sublingual PRN, and Ambien 5 mg. p.o. Q h.s. for sleep but apparently has not had much treatment for the anxiety or depression she is suffering. Lortab one tab Q 4-6 hrs PRN pain, Ducolax 5 mg. p.o. Q day PRN constipation. She has also been taking Benadryl for a rash and to help her sleep.

PAST MEDICAL HISTORY

As noted, she had a hip fracture in June, 1995. She had her gallbladder removed in 1994 as well as procedure on small intestine. She has apparently had a wrist and ankle fracture secondary to osteoporosis.

C O N T I N U E D ….

Anderson, ELLEN

PAGE 2 . . .

ROBERT WEITZEL, M.D.

SOCIAL HISTORY

The patient has been widowed for 28 years. She has been a teacher in grade school and has had some college. She is LDS. She does not smoke or drink.

FAMILY HISTORY

Negative.

Alcohol and drug history are negative.

PATIENT STRENGTHS

Supportive family.

PATIENT LIMITATIONS

Dementia, multiple medical problems, and unable to respond to questions.

MENTAL STATUS EXAMINATION

She is a frail appearing white female. Speech is nonfluent and mood is very dysphoric. Affect is congruent with mood. Somewhat labile. Thought processes completely loose, thought content is difficult to ascertain. Seems to revolve around requests for family to be close. Hearing is fair. Eyesight is fair. I.Q. is untestable. Calculations, memory, abstractions, and fund of knowledge were not testable. Insight poor. Judgement poor.

DIAGNOSIS

Axis I: Major depression with psychotic features and anxiety disorder.

Axis II: Defer.

Axis III: Dementia, osteoporosis, history of hypertension and angina.

Axis IV: 3

Axis V : 22

C O N T I N U E D …

PSYCHIATRIC EVALUATION

Anderson, ELLEN

PAGE 3 …

ROBERT WEITZEL, M.D.

DISCUSSION & RECOMMENDATIONS

Initially we will continue her current medications and we will get medical workup completed. Most probably will use benzodiazepines for quick control of her anxiety and antidepressant such as Serzone or Paxil to control both anxiety and depression. Risperdal may be needed to control psychotic behavior. Also will use morphine sulfate for pain control.

ESTIMATED LENGTH OF HOSPITALIZATION

Two to three weeks.

DISCHARGE CRITERIA

Decreased depression and anxiety.

DISCHARGE PLAN

Back to Pioneer Care Center.

(Signed) Robert Weitzel, M.D.

RW/re

D: 12/30/95 12:20

T: 12/30/95 14:01

Job# 3850

PSYCHIATRIC EVALUATION

Psych Eval Discharge Summary Living Will / Medical Treatment Plan

Physician's Orders Progress Notes Nursing Staff Notes Nursing Admission Assessment

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