HPI: This 26 year old white female was seen in this ED yesterday afternoon with acute
onset of paranoid behavior. This had begun yesterday morning with the pt. running
around the house, ringing bells, and looking behind light switches, books, etc. She
felt the house had been "bugged" and she was looking for these bugs or wire
taps. She had not slept very much the previous night. Her behavior was bizarre
and somewhat illogical per her husband, and he brought her to the ED. He noted she
had had some intimations of similar behavior previously, i.e., a feeling that the parents
of the children that she teaches in Sunday school had gotten together and decided to make
the children act poorly in order to annoy her. Dr. Rody's exam showed basically a
normal neurologic exam at that time. Concentration was poor. Attention was
poor, and ability for abstract thought was impaired. Lab evaluation was
unremarkable. The pt. was felt to be suffering a probable acute psychotic break
manifest by paranoid schizophrenia, and was discussed with Dr. young, covering for her reg.
Pacificare phys., Dr. Levy, with Dr. Smith, the Psychiatrist on call for the
OCC, and with
Pacificare benefits people who informed Dr. Rody that she was not covered for inpatient
psychiatric care. She was transferred to the Crisis Center, and from there
apparently on an EOD to Central State Hosp. Dr. Morgan, covering for Dr. Levy, and
myself were both contacted today by the psychiatrist on duty today at Central State
Hosp. He noted the pt. was confused, paranoid with word salad, and other typical
ROS: As above.
PH: As above.
MEDICAL DECISION MAKING:
At this point, I have discussed with pt.'s husband, father, mother, and other members of the family LP. I have discussed the indications for, benefits of, and risks of this procedure, the latter including but not limited to bleeding, infection, damage to spinal nerves. They do not wish her to undergo LP at this time (I do not feel pt. is currently competent to make this decision for herself). I have explained to them the risks of untreated subarachnoid hemorrhage or meningitis, including brain damage and death, and they understand to my satisfaction.
The pt. has been discussed with Dr. Morgan, very extensively discussed with the family, and again discussed with Dr. Morgan. She will be admitted to Presbyterian Hosp. for observation and further neurologic evaluation as indicated. She will be admitted under suicide precautions, and I have asked that a family member be available to stay with her in the room 24 hrs. a day, and this is agreeable to them as well. Admitting orders are written by me per Dr. Morgan's preferences following consultation with him. See orders.
ASSESSMENT: Acute psychotic episode; R/O toxic/metabolic/structural pathology.
DMA: skv DAVID M. ABERCROMBIE, M.D.