DAVIS HOSPITAL & MEDICAL CENTER

COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL

PSYCHIATRIC EVALUATION

PATIENT: Larsen, Judith

Robert Weitzel MD

Admit: 12/06/95

CHIEF COMPLAINT

The patient’s family complains that she has been quite agitated, screaming, shouting nonsensical syllables and is demented.

IDENTIFYING INFORMATION

The patient is a 93 year-old widowed white female, who had been living in the Holladay Health Care Center.

HISTORY

The patient reportedly had a stroke in August and was unable to speak or swallow but apparently after sustaining a head laceration after a fall out of bed she was once again able to speak and swallow. Lately she has become very upset and agitated and has had poor intake and has needed assistance with all of her ADLs and has had quite bizarre behavior. She is crying, shouting when awake, sleeping most of the time and is fairly unresponsive. She fights against restraints. The patient has lost continence of bowel and bladder.

PAST PSYCHIATRIC HISTORY

The patient was hospitalized in the late 50s and had ECT for depression. There is no history of her being on antidepressants recently.

PAST MEDICAL HISTORY

As noted above she had CVA apparently 8/25/95, there are multiple old infarcts on CT scan.

MEDICATIONS: Currently include Synthroid 0.088 mg. q. day, Isordil 10 mg b.i.d., one baby aspirin per day, Trazodone one q. h.s., Xanax 0.5 mg p.o. t.i.d. and Betagan 0.5% one drop each eye b.i.d. as well as Zantac 150 mg q. day. She had had a history of several falls from bed in the last year and in 1985 through 1990 she had bilateral cataract surgery and apparently in the 1930s she may have had a thyroid goiter. In 1954 she had a hysterectomy.

Continued….

Judith Larsen

Page 2…. PE

Robert A. Weitzel, M.D.

SOCIAL HISTORY

The patient has been living in the Holladay Health Care Center. She has supportive children. Apparently she believes her son to be her husband, who has died. She dropped out of high school and got married at age 16. She has been a homemaker and seamstress. She is a member of the L.D.S. Church. She does not smoke or drink.

FAMILY HISTORY

Negative for psychiatric. There is some thyroid disease in the family.

PATIENT STRENGTHS

Support of family.

PATIENT LIMITATIONS

Dementia and nonresponsive at the time of examination.

MENTAL STATUS EXAMINATION

The patient is an elderly female, who appears undistressed. Speech exhibits echolalia, mood is very dysphoric, affect is congruent, somewhat labile. The thought process is very loose. Thought content is difficult to ascertain. She is unresponsive. She apparently hears and sees but it is difficult to ascertain to what level. IQ seems very low. Calculations were not tested. Memory is not testable. Abstractions not testable. Fund of knowledge is not testable. Insight is poor. Judgment is poor.

DIAGNOSIS

Axis I: Major depression with psychotic features. Rule out organic brain syndrome.

Axis II: Defer.
Axis III: CVA, hypothyroidism.

Axis IV: Three.

Axis V: Fifteen.

DISCUSSION & RECOMMENDATIONS

We will get full medical work-up and probably start Serzone and Respirdol.

Continued…

Judith Larsen

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Robert Weitzel MD

ESTIMATED LENGTH OF HOSPITALIZATION