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Assessment
(Peter Morgan, MD - April 27, 1992)

PATIENT: Burns, Jolynne
DATE: 4/27/92
PHYSICIAN: Peter Morgan, M.D.

HISTORY AND PHYSICAL

History of present illness:
This is a 26-year-old white female who was admitted through the Emergency Room after transfer from Griffin Memorial Hospital (Central State).  The patient initially was brought to the Emergency Room last evening at Presbyterian Hospital with an acute psychotic outburst.  She was evaluated in the Emergency Room and felt to be having psychiatric problem.  She was referred to the Crisis Center and then an emergency order of detention was written for her to be admitted to Central State Hospital.

Dr. Weathers, at Griffin Memorial Hospital, felt that the patient had an abnormal neurological examination early this morning.  He therefore called our office.  (Dr. Levy is the patient's primary care physician, and I am covering for Dr. Levy.)  It was felt that she was going to need to be evaluated for other medical problems before further psychiatric evaluating could be done.

The patient has no prior history of psychotic outbursts or psychotic behavior.   Further history reveals that she has been behaving somewhat abnormally for the past several months with occasional paranoid behaviors according to the husband.  This became much more pronounced in the last 24-48 hours.

Past medical history:
Fairly unremarkable.  She had wisdom teeth removed as a teen.  She is currently on birth control pills and takes Benadryl for urticaria which she gets periodically.   She was seen in the office in February for slight swelling to the right side of the face, which was associated with some itching and there was urticaria at that time as well.   She was started on Medrol Dosepak after being given Decadron IM injection.   Apparently the swelling totally resolved at that time, but she continues to have periodic episodes of urticaria which seem to be somewhat stress related.  She takes occasional Benadryl for these which does relieve the pruritis to some extent.

Family history:
Patient's mother has had breast cancer and has had urticaria as well.  Apparently this is also stress related.  The patient's maternal grandmother has had lupus and diabetes.  The patient's maternal grandmother died of lung cancer.  There is some heart disease on the father's side of the family.

Social history:
The patient denies tobacco or alcohol usage.  She drinks one or two Cokes daily.   She has been under extreme stress recently with a recent move to the Oklahoma City area.  She has no friends in this area and is unable to find a job at present except in a day care center.

Physical examination:
General: well-developed, well-nourished, slightly obese, white female who is in no acute distress.  Her affect seems somewhat flat and she does smile inappropriately at times when answering questions.

Vital signs: Blood pressure 126/80, pulse 80, afebrile.

HEENT: Pupils equal, round, and reactive to light and accommodation.  The extraocular movements were intact.  The fundi appeared completely benign.  There did seem to be very slight nystagmus with rapid horizontal eye movements in each direction.   This is very subtle and not reproducible at all times.  The tympanic membranes were both clear.  The throat was fairly clear, although not very well seen.   Tongue protrudes in the midline.

Neck: Supple without jugular venous distention, thyromegaly or bruits

Lungs: Clear to auscultation and percussion.

Heart: Regular rate and rhythm with no S3.  No murmur or rub.

Abdomen: Slightly obese, soft, nontender, no organomegaly.  Normal active bowel sounds.  No bruit.

Extremities: No clubbing, cyanosis or edema.

Neurologic: Cranial nerves II though XII were intact.  There was the slight nystagmus on horizontal gaze both directions, but no vertical nystagmus.  The MSR's are all symmetrical.  The upper extremity MSR's are 3+ at the brachial radialis, 2+ elsewhere, and symmetrical.  She has 3+ knee jerk and 3+ ankle jerk reflexes with very brisk return of reflexes.  There was bout three beat clonus bilaterally at the ankles.  There is no Babinski.  There is no Romberg.    Finger-to-nose and heel-to-shin tests were intact.  When testing for drift, the patient just suddenly started making movements with her arms which followed no particular pattern or abnormality that I am familiar with.

Integument: The patient had a very slight amount of an erythematous blanching macular/papular rash on the upper back.  They are urticarial in appearance.

Laboratory data:
Drug screen was negative tonight.  Last night the patient had normal electrolytes, glucose, magnesium and phosphate.  The complete blood count was normal.  CT scan of the head with and without infusion this evening is completely within normal limits.  

Impression:
1. Altered mental status and psychotic behavior of uncertain etiology.  The examination is benign with the exception of the patient's hyper-reflexia.  This is somewhat puzzling and I believe necessitates further neurologic evaluation.

Plan:
1. We therefore will get a neurologic consultation with Dr. Dow.
2. In addition, we will get a TSH level and a T4 to evaluate thyroid status and will draw an ANA and sedimentation rate to look for the possibility of lupus.

Peter Morgan, M.D.
D/T 4/27 4/28/92 rh