History of Present Illness: Increasing confusion, Major neurocognitive disorder dementia Social History: Son killed during Gulf War. Daughter-in-law Betty and her son Ty visit frequently. Used to be very active in her church and loved to cook, read, and do quilting. Cannot concentrate long enough to engage in these activities now. Ertha and husband Henry moved into assisted living facility approximately 11 months ago. Henry died about 7 months ago, shortly before her transfer to this long-term care facility. Primary Medical Diagnosis: Major neurocognitive disorder Alzheimer’s vs. Vascular Type Surgeries/Procedures & Dates: Hysterectomy at age 38 How will you communicate with the patient?
It is four months after Ertha's transfer to the long-term care facility. She is even more confused, going into other patient's rooms looking for Henry and stealing items. She recently began striking out at other residents, and staff finds food stashed under her mattress. She has been taking two antidepressant medications, an anti-anxiety agent and Aricept for the past four months but there has been no improvement.
Brief Description of Client
Name: Ertha Williams
Date of Birth: 01/19/xx
Gender: F
Age: 74
Weight: 124 lb (63.5 kg) Height: 64 in
Race: (Faculty can select)
Religion: (Faculty can select)
Major Support: Betty Williams (daughter-in-law)
Support Phone: 320-222-1111
Allergies: none known
Immunizations: up to date
Attending Provider/Team: Joan Rivers, MD, and Mary Lake, MS, APRN/Geriatric Nurse Practitioner
Past Medical History: Hypertension, depression, hyperlipidemia, arthritis
History of Present Illness: Increasing confusion, Major neurocognitive disorder dementia
Social History: Son killed during Gulf War. Daughter-in-law Betty and her son Ty visit frequently. Used to be very active in her church and loved to cook, read, and do quilting. Cannot concentrate long enough to engage in these activities now. Ertha and husband Henry moved into assisted living facility approximately 11 months ago. Henry died about 7 months ago, shortly before her transfer to this long-term care facility.
Primary Medical Diagnosis: Major neurocognitive disorder Alzheimer’s vs. Vascular Type
Surgeries/Procedures & Dates: Hysterectomy at age 38
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