Toxic Metabolic Encephalopathy Case Study

A review of his medical record indicates a history of CHF, toxic metabolic encephalopathy, CKD stage 3, bilateral pleural effusion, generalized weakness, HTN, severe debility, impaired gait, functional deficits, actinic keratosis, adjustment disorder with depressed mood, Alzheimer’s dementia disease with late onset with behavioral disturbance, atherosclerotic heart disease of native coronary artery without angina pectoris, lymphedema, not elsewhere classified, mixed hyperlipidemia and muscle weakness.
At today’s visit he is accompanied by his case manager Laura. He is awake and disoriented. He appears confused and is a poor historian due to his Alzheimer dementia. A review of his chart indicates that he was recently admitted to Brennity memory care unit. His admission was predicated by a fall in august while at …show more content…
He had a fall on 8/11/16 was sent to the ER, he complained of progressive SOB while in the ER and was found to have pulmonary edema. He was treated with intravenous diuretic therapy and Bi-pap therapy in the ER. He was very weak, having difficulties ambulating; as a result he was transferred to emerald healthcare for rehab. He was then transferred to Brennity ALF because his wife could not care for him at home. His case manager reports that he has had CHF exacerbation in July and august of 2016. He has tachy-brady syndrome for which he has an implanted pacemaker. He also has encephalopathy. He had a recent fall on 9/19/16 and sustained trauma wound to right forearm and ecchymosis area to scalp. He needs assistance with some ADLS. His gait is unsteady, he needs guidance when ambulating. He is confused and has daily sun downing in the evening. He has Ativan gel order as needed and takes Seroquel for agitation. Due to his impaired memory and unsteady gait, is takes