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COLORS:  RED - PAIN   ORANGE - AGITATION   GREEN - TERMINAL

PATIENT: Larsen, Judith

DATE OF CONSULTATION: 12/08/95

ATTENDING PHYSICIAN: Robert A. Weitzel, M.D.

CONSULTING PHYSICIAN: David Dienhart, M.D.

Admission to the psychiatric unit for worsened dementia/provisional psychoses, evaluation of medical problems.

This is a 93 year-old female who by history suffered a cerebrovascular accident in January of 1995. Since that time she has been less communicative. By history she was living in a retirement center as late as July 1995. She has recently been residing in the Holladay Health Care Center. Since late August 1995 she has had essentially no speech, she has been restrained in bed, she has fallen out of bed and received head lacerations.

Remarkable for cerebrovascular accidents, diagnosis of ischemic heart disease, history of angina, hypothyroidism, status post thyroidectomy, history of nephrolithiasis and history of hiatal hernia with gastroesophageal reflux disease.

On examination today the patient does not communicate. She does not verbally explain of any pain.

MEDICATIONS: Betagen 0.5% one drop each eye b.i.d., Surfak one p.o. q. day h.s., Clonopin 0.5 mg p.o. t.i.d., Trazodone 100 mg p.o. q. h.s. Synthroid 0.88 mg one p.o. q. day, baby aspirin one p.o. q. day. Isosorbide 10 mg p.o. b.i.d. Ativan 1-2 mg p.o. IM q. 6 hours p.r.n. agitation. Zantac 150 mg p.o. daily p.r.n. abdominal pain.

Continued…

 REPORT OF CONSULTATION

Judith Larsen

Page 2 … CO

David Dienhart, M.D.

MEDICAL: Past history of cerebrovascular accident in January of 1995. Note: CT scans of the brain on 8/26/95 and 9/14/95 showing no evidence of acute cerebrovascular injury. There is left frontal and occipital encephalomalacia consistent with old areas of infarction, which are unchanged on the 9/14/95 when compared to the 8/26/90. On examination there is diffuse white matter changes and small vessel disease. These areas of encephalomalacia are felt to be large areas involving the left frontal and occipital lobes.

There is the past medical history of ischemic heart disease with angina, undefined in the medical record. History of hypothyroidism, status post thyroidectomy with unclear reason for thyroidectomy. History of multiple falls in the last year. History of nephrolithiasis. Elevated glucose on history and physical of 9/14/95 by Dr. Stevens.

Per past dictation the patient has no history of alcohol or tobacco use.

GENERAL: The patient is a 93 year-old thin female who is supine at rest in bed. The patient is observed to ambulate with a very small gait, shuffle, with assistance.

VITAL SIGNS: Respirations are 16-20 per minute. Heart rate is about 70 per minute. Temperature is 97 degrees. Blood pressure is 107/60.

HEENT: The left eye shows evidence of a left iridectomy and is nonreactive. The right pupil is approximately 2 mm and minimally reactive. The conjunctiva are pink. Tympanic membranes are clear of cerumen. The throat is clear. There are upper dentures. The lower teeth are only in fair repair. The tongue is red and dry suggesting early oral thrush.

NECK: Supple. There is no adenopathy.

AXILLAR: No adenopathy.

BREASTS: Pendulous, showing no evidence of mass.

CARDIAC: Regular.

Continued….

REPORT OF CONSULTATION

Judith Larsen

Page 3 … CO

David Dienhart, M.D.

LUNGS: There are poor breath excursions and poor cooperation without rales or wheezes appreciated.

ABDOMEN: Soft, nontender. There is no hepatomegaly.

EXTREMITIES: No edema.

NEUROLOGIC: There are 2+ biceps, ¼+ knee jerks bilaterally.

There is no Babinski.

Chest x-ray on admission shows cardiomegaly, probably large hiatal hernia. There is no evidence of infiltrate. EKG from 12/6/95 shows a probable sinus rhythm at 79 beats per minute. There is slightly unusual P wave axis suggesting a possible extopic atrial rhythm. There is occasional premature ventricular supraventricular complexes. There is a left anterior vesicular block. Poor R wave progression V1 through V4, suggesting old septal infarction. The R wave is low amplitude V4 through V6.

LABORATORY DATA On 12/6/95 sodium 136, potassium 4.3, chloride 103, CO2 30, anion gap 3, glucose 163, BUN 18, creatinine 0.8, calcium 9.8, uric acid 4.7, cholesterol 197, triglycerides 119, total protein 7.4, albumin 3.3, globulins 4.1. total bilirubin 0.6, alkaline phosphatase 58.GGT 13, ALT 11, AST 23, LDH 188. Phosphorous 3.1, magnesium 1.9. Iron 25. TSH 3.1. T3 29.6, T4 8.6, T7 2.55. WBCs 5,100, hemoglobin 13.7 hematocrit 41.2. Platelet count 274,000. RPR is nonreactive. Urinalysis color yellow, appearance clear, specific Gravity 1.015, pH 5.0, WBCs 1-2, bacteria 2+

IMPRESSION

1. Severe dementia, confusion, provisional psychoses.
2. History of cerebrovascular accident January 1995 with recent CT scan showing cephalomalasia in the left frontal and occipital regions and small vessel white matter disease.
3. History of ischemic heart disease with angina, unclear of documented past myocardial infarction.
4. Cardiomegaly on current chest radiography, unknown LV function.
5. History of hypothyroidism on thyroid replacement, status post thyroidectomy for unclear reasons years ago.
6. Status post multiple falls.
7. Status post hysterectomy.
8. Status post nephrolithiasis.
9. Probable current oral thrush, early.

   Continued

   Judith L.

   Page 4 … CO

   David Dienhart, M.D.

10. Large hiatal hernia with history of gastroesophageal reflux disease.
11. Hypoalbuminemia, hypergammaglobulinemia, etiology of increased globulin fraction unclear, may be secondary to inflammatory process or uncontrolled glucose, or evidence of a monoclone dermopathy.
12. History of hyperglycemia 9-95, evaluation at Cottonwood Hospital.

1. therapy or oral thrush with Nystatin.
2. Serum protein electrophoresis.
3. Glycosylated hemoglobin to assess long term glucose control.
4. Check periodic oxygen saturations, with check at night while sleeping to screen for oxygen desaturation.

Thank you for asking me to evaluate this patient.

(Signed) David Dienhart, M.D.

DD/lw

D: 12/08/95 08:14

T: 12/08/95 13:37

Job #00140

REPORT OF CONSULATION

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