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Assessment
(Robert W Dow, MD - April 28, 1992)

NAME: Burns, Jolynne    cc    Peter Morgan, M.D.
DATE: 4-28-92
PHYSICIAN: Dow

CONSULTATION NOTE

HISTORY OF PRESENT ILLNESS:
Ms. Burns is a young woman whom I have been asked to see by Dr. Morgan for evaluation of an acute psychosis.  She was evaluated in a local clinic and sent to Griffin State Hospital, where on evaluation the attending psychiatrist felt that she had focal neurological symptoms which needed more attention.  Subsequently, she was transferred back to HCA Presbyterian Hospital and admitted.

PAST HISTORY:
In talking with her family, it seems that for many years she has been an uncoordinated individual, walking with a wide base.  She is left handed and has some difficulty handling eating utensils.  This too has been attributed to the left handedness.   Perhaps this has increased a bit over the past month.  Over the past several days, she has developed a very dramatic change in her mental status with paranoid delusions and agitation and is plainly psychotic.  There is no preexisting history of this.  She has no past history of blackout spells, epilepsy or significant head injury, though at age four she did have a head injury which rendered her unconscious for a short period.  There is no recent history of headache or transient focal neurological disturbance.

PHYSICAL EXAM:
A complete Neurologic examination was performed.  There was some perseveration on commands and she was concrete at times, following the commands of the examination.   Her cranial nerves are normal two through twelve, including funduscopic and visual fields.  There is no inattention or neglect.  Her cranial nerves are normal two through twelve.  Motor examination shows symmetric tone, strength and no drift.   Deep tendon reflexes are symmetric and toe signs are downgoing.  Coordination testing shows normal rapid alternating movements and finger-nose-finger in the upper extremities.  Her spontaneous gait is abnormal in that it has a
base of approximately 8 inches.  Tandem walk was not assessed in this setting.

ASSESSMENT:
I think there is a concern because of the abnormal gait and the acute change in her thinking.  It is my feeling that the change in her thinking likely has a psychiatric basis rather than a true organic basis.  I think, though, that we should do an MRI scan of her brain and an EEG to be sure that we are not overlooking any other process at this time.  These have been requested.

Robert W. Dow, M.D.
D,T:  4-28/4-29-92/vs