PRESENTING COMPLAINT: This (XX)-year-old lady was brought to the emergency room in police custody on a PEC secondary to dementia and psychosis.
HISTORY OF PRESENTING COMPLAINT: The history obtained is severely limited due to the patient’s dementia. The patient states that her husband has been cheating on her. She has multiple versions of this, including her coming downstairs and finding him bringing other women into the house, noticing other women looking at him on the street, knowing that other women know all about the affair that they are having. She is preoccupied with this throughout the interview. She states that they have been married for over (XX) years and they have 5 children; although, she is unable to tell me their ages. The patient states that she has been sleeping and eating well. She denies any suicidality but does state that she wants to kill her husband. She is paranoid about her husband and this paranoia does not appear to have generalized to any other situations.
PAST PSYCHIATRIC HISTORY: The patient appears to have a history of depression and she is not able to give me any further details. She states that she overdosed at some point in the past but is unable to tell me when or what happened. She is unable to tell me the name of her medications and denies any other psychiatric admissions; although, it is unclear whether this is reliable information.
MEDICAL HISTORY: Medical history, from her notes, includes hypertension, heart disease, dementia, hypothyroidism and hyperlipidemia. It is of note that though her records indicate a possibility of diabetes, both the patient and her daughter report that the patient does not have diabetes.
MEDICATIONS: Detrol LA 4 mg 1 by mouth at bedtime, nitrofurantoin MCR 50 mg 1 by mouth daily, Namenda 10 mg 1 by mouth twice a day, Plavix 75 mg 1 by mouth daily, TriCor 145 mg 1 by mouth daily, metoprolol 50 mg 1 twice a day, levothyroxine 50 mcg 1 by mouth daily, Evista 60 mg 1 every morning, Lexapro 10 mg 1 daily, Diovan 160 mg 1 daily, simvastatin 40 mg 1 daily, Exelon patch 9.5 mg per 24 hours 1 patch daily, fiber laxative and multivitamin daily.
ALLERGIES: The patient has allergies to SULFA and PENICILLIN.
SOCIAL HISTORY: The patient lives with her husband to whom she has been married for approximately (XX) years. At least 1 daughter is involved and supported in her care. The patient tells me that she was born and raised in (XX), the 4th of 12 siblings, 3 of whom are deceased. She states that she worked in the corn fields and then in a factory both before and after her children were born. She is unable to give me any further information.
FAMILY HISTORY: Unobtainable.
MENTAL STATUS EXAMINATION: Revealed a short (XX)-year-old lady, casually and appropriately dressed. She was pleasant and cooperative with the interview. Her speech was preoccupied with her husband’s presumed infidelity. She had no disorder of thought. Her mood she described as angry with her husband. Her affect was mood congruent. She denies any difficulties with sleep or appetite. She denies suicidality stating “he is not worth it.” She does endorse homicidal ideation towards her husband. She is exhibiting paranoid delusions as outlined above. No evidence of perceptual abnormalities. Her cognition is severely limited. Mini-Mental score is 19 out of a possible 30. The patient was oriented to place and to time. She could register new information but could not recall any words in 5 minutes. She was unable to read and obey a sentence. She was unable to copy a design. She was unable to complete a 3-stage command.
GENERAL: Revealed a (XX)-year-old woman in no acute distress.
HEAD AND NECK: Trachea midline. No lymphadenopathy. Neck supple.
CHEST: Heart sounds 1 and 2, nil added. Fungal rash evident under both breasts.
ABDOMEN: Soft and nontender. Groin fungal rash evident. Bowel sounds normal.
NEUROLOGIC: Cranial nerves II-XII grossly intact. Reflexes brisk throughout. Plantars downgoing. Gait normal.
DSM-IV DIAGNOSES:
AXIS I: Paranoid psychosis, dementia.
AXIS II: Deferred.
AXIS III: Hypertension, coronary artery disease, hyperlipidemia, hypothyroidism, abdominal aortic aneurysm.
AXIS IV: Related to illness.
AXIS V: Global Assessment of Functioning of 25.
TREATMENT PLAN: The patient has been admitted and placed on every 15-minute checks for safety. She will continue to have her usual medications. Her mood will be assessed and her psychosis treated with low-dose haloperidol. Her discharge plan is dependent on to what degree her psychosis resolves to. Her level of functioning will be assessed to determine whether she is appropriate to return home and whether it is safe for her to return to live with her husband.
