A review of her medical record indicates a medical history of adult failure to thrive with progressive decline poor appetite and dysphagia, with result in PEG tube place for supplemental feeding of glucerna 240 mg bolus every 6 hours. She had brain surgery earlier this year, after having a fall at home and diagnostic head CT showed large 10 cm parietal cystic lesion, shifting the brain structure midline with a shift 12 mm of the right side shift of the septum and a large arachnoid cyst in the area. Her other medical history includes HTN, dysphagia, NIDDM, major depression, muscle weakness, GERD, Chronic ischemic heart disease, cerebral cyst and convulsion.
At today’s visit she is found lying in her bed at tiffany hall SNF facility. She is
At today’s visit she is found lying in her bed at tiffany hall SNF facility. She is