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DAVIS HOSPITAL & MEDICAL CENTER
PSYCHIATRIC EVALUATION
PATIENT: Alldredge, Ennis
Robert A. Weitzel, M.D.
1/10/96
IDENTIFYING INFORMATION
This is a 82-year-old, married white male who has been living at the Sunshine Terrace Nursing home.
CHIEF COMPLAINT
"Who are you."
HISTORY
The patient has recently become very aggressive and combative, hitting and kicking people. He had to be restrained in a geri-chair. He has had dementia diagnosis for some time, but only recently has become a risk to himself and other residents and staff. He does exhibit sun-downing. Ativan up to 3 mg IM times 2 has been tried, but has often not been helpful. He also has been prescribed Risperdal ½ mg and a 1 mg b.i.d., but this has not been helpful. He has been having negative incidents daily. I spoke with Dr. Cunningham in Logan yesterday and approved admission. I was not informed that he is non-ambulatory before the admission.
PAST PSYCHIATRIC HISTORY
Negative.
PAST MEDICAL HISTORY
He had a hernia repair in 1990. He apparently has had a CABG. He has been a diabetic since the 1970s. He is on fairly high doses of insulin, i.e. lente 20 units q a.m. and 5 units q p.m. He is on Pepcid 20 mg q day. He was on Risperdal and that has been increased here. He had been on Benadryl for sleep and this has been changed to Trazodone here. He has been on Bumex 1 mg q a.m., aspirin 325 mg b.i.d., Oxybutynin 5 mg po b.i.d., Micro-K 10 mEq q day, Hytrin 5 mg q hs, DSS 100 mg po b.i.d., and Buspar 10 mg po t.i.d. Basically his latest labs which were faxed to us appear to show no major abnormalities.
continued…..
PSYCHIATRIC EVALUATION
ALLDREDGE, Ennis
continued…pg2
Robert A. Weitzel, M.D.
SOCIAL HISTORY
The patient is married, but he is in a nursing home. His wife does not live there, of course.
FAMILY HISTORY
Negative for psychiatric disorder.
SUBSTANCE USE: Alcohol and drug history are negative.
PATIENT STRENGTHS
None that I am aware of.
PATIENT LIMITATIONS
Dementia, combative behavior, multiple medical illnesses.
MENTAL STATUS EXAMINATION
In general, he is an elderly appearing white male who is agitated and difficult to control. Speech – he has some slurring. Mood is quite dysphoric. Affect – congruent and labile. Thought process – quite loose and exhibits blocking. Thought content – difficult to ascertain secondary to patient being uncooperative. Perceptions – hearing and vision seem adequate. Cognition – IQ seems grossly impaired. Calculations not tested. Memory is very poor, obviously, but he will not cooperate with testing. Abstractions – not tested. Fund of knowledge – not tested. Insight – poor. Judgement – poor.
DIAGNOSIS
Axis I: Psychosis NOS.
Axis II: Defer.
Axis III: Dementia, history of dyspepsia, possible peptic ulcer disease treated with Pepcid. Hypertension treated with Bumetanide and Hytrin. Hyperthyroid treated with L-thyroxin. Constipation treated with Docusate sodium.
Axis IV: 4.
Axis V: 22.
continued….
PSYCHIATRIC EVALUATION
ALLDREDGE, Ennis
continued…pg3
Robert A. Weitzel, M.D.
DISCUSSION & RECOMMENDATIONS
We will quickly control his psychotic behavior with some IM Haldol and Ativan. He has currently received these and is doing well. I would like to have him on a higher dose of Risperdal. I will continue the Buspar. He will probably be started on Depakene as needed and he will have prn Ativan and Haldol.
ESTIMATED LENGTH OF HOSPITALIZATION
2 to 3 weeks.
DISCHARGE CRITERIA
No combativeness.
DISCHARGE PLAN
Back to Sunshine Terrace.
(Signed) Robert A. Weitzel, M.D.
RAW/kl
D: 1/10/96 16:25
T: 1/10/96 16:39
Job # 5699
Psych Eval History & Physical Discharge Summary
Living Will / Medical Treatment Plan