(Robert W Dow, MD - April 28, 1992)
Jolynne cc Peter Morgan, M.D.
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.
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.
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.
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.