PMBK Dementia/Confusion

Admitting Diagnosis
[textarea name="variable_1" default="Functional Decline"]
[select name="variable_1" value="
Initial Consultation|Follow up"]
[date name="variable_1" default="10-12-2022"]
[remark]content[/remark]
History of Presenting Illness:
[textarea name="variable_2" default="Admitted to Water's Edge on * for rehabilitation in the setting of functional decline from medical conditions. Patient was seen and examined at bedside. Resting comfortably in bed. Alert, awake, and confused. Patient is a poor historian. Medical and functional history was obtained from both the patient and throught chart review. Does not appear to be in any pain or distress."]
[remark]content[/remark]
A consultation was requested to assess rehabilitation needs, develop a rehabilitation plan of care and address rehabilitation medicine diagnoses and their related issues.
[remark]content[/remark]
Allergies: [textarea name="variable_3" default="No Known Allergies"]
Past Surgical History: [textarea name="variable_4" default="Patient is confused and is unable to provide SHx"]
Family History: [textarea name="variable_5" default="Patient is confused and is unable to provide FHx"]
[remark]content[/remark]
Prior Functional History:
Before admission, patient was able to mobilize themselves independently
Previous Ambulation Devices:
[checkbox name="variable_1" value="No Device|Cane|Walker"][checkbox name="variable_2" value="Rollator|Wheelchair|Not Previously Ambulating"]
Patient's Prior Activities of Daily Living:
[checkbox name="variable_3" value="Dependent/Refused|Maximal Assistance|Moderate Assistance"][checkbox name="variable_4" value="Minimal Assistance|Setup but otherwise Independent|Independent"][checkbox name="variable_5" value="Assistance with Homemaking|Assistance with Grooming|"]
[remark]content[/remark]
Social History:
Residence - [textarea name="variable_6" default="Patient lives in an ALF. Hx of ETOH/Tobacco usage. "]
[remark]content[/remark]
Pain Medication:
[textarea name="variable_7" default="Tylenol 650mg, Lidocaine Patch"]
[remark]content[/remark]
Medications:
[textarea name="variable_8" default="I have reviewed the patient's medications"]
[remark]content[/remark]
Review of Systems: Patient is confused and is unable to provide ROS. Does not appear to be in any pain or distress. 
General
[checklist name="variable_1" value="Fatigue|Sleep Disturbances|Recent Falls"]
Neurological
[checklist name="variable_2" value="Dizziness|Syncope|Headache"][checklist name="variable_3" value="Coordination Changes|Weakness|Numbness"]
HEENT
[checklist name="variable_4" value="Vision Changes|Eye Pain|Ear Pain"][checklist name="variable_5" value="Dysphagia|Hearing Changes|Throat Pain"]
Cardiovascular
[checklist name="variable_6" value="Chest Pain|Palpitations"]
Respiratory
[checklist name="variable_7" value="Shortness of Breath|Wheezing|Cough"]
Gastrointestinal
[checklist name="variable_8" value="Nausea|Vomiting|Diarrhea"][checklist name="variable_9" value="Constipation|Abdominal Pain"]
Genitourinary
[checklist name="variable_10" value="Difficulty Urinating|Dysuria|Urinary Incontinence"]
Musculoskeletal
[checklist name="variable_11" value="Low Back Pain|Arthralgia|Myalgia"]
[remark]content[/remark]
Physical Exam:
Vital Signs - [textarea name="variable_9" default=""]
General - [textarea name="variable_10" default="No acute distress, Frail appearing"]
HEENT - [textarea name="variable_11" default="Head is normocephalic, atraumatic. No scleral icterus, no conjunctival pallor. "]
Neurological - [textarea name="variable_12" default="Alert and Confused, Intermittently following commands."]
Pulmonary - [textarea name="variable_13" default="Clear to auscultation B/L, no wheezing. Respiratory efforts within normal limits. Unlabored breathing."]
Cardiovascular - [textarea name="variable_14" default="Regular rate and rhythm, adequate perfusion"]
Gastrointestinal - [textarea name="variable_15" default="Abdomen soft, nontender, nondistended. No guarding."]
Musculoskeletal - [textarea name="variable_16" default="ROM in upper and lower extremities WFL. Demonstrates ability to move all extremities against gravity and with resistance. --- Unable to assess ROM/strength in extremities as patient does not cooperative with exam/following commands for exam. "]
[remark]content[/remark]
Diagnostic Studies
[checkbox name="variable_6" value="I have reviewed this patient's lab results|No current labs at this time|I have reviewed this patient's diagnostic imaging"][checkbox name="variable_7" value="No pertinent diagnostic imaging to review at this time|"]
[remark]content[/remark]
Assessment:
[textarea name="variable_17" default=""]
[checkbox name="variable_8" value="R26.9-Repeated Falls|R13.12-Dysphagia,oropharyngeal phase|I69.328-Oth Speech/language deficits following CVA"][checkbox name="variable_9" value="M13.0-Polyarthritis, unspecified|M86.00-Osteomyelitis|M48.9-Spondylopathy, unspecified"][checkbox name="variable_10" value="M62.81-Muscle Weakness|M62.40-Contracture of muscle, unspecified|R53.81-Deconditioning"][checkbox name="variable_11" value="M79.2-Neuropathic pain|R26.2-Walking difficulty|R26.9-Unspecified abnormality of gait or mobility"][checkbox name="variable_12" value="Z73.6-Decreased ADL|Z74.09-Chairridden|Z74.1-Need assistance with personal care"]
Plan:
[textarea name="variable_18" default="Pain Regimen: Controlled on current pain regimen. No changes recommended. Tylenol 650mg, Lidocaine Patch, Dose PRN pain medications prior to therapies Please hold all opiates for any lethargy, sedation or respiratory depression that is noted "]
Physical Therapy:
- Improve bed mobility and transfers through upper and lower body strengthening
- Perform progressive gait training including instruction in negotiating barriers and obstacles
- Emphasis on improving sitting/standing balance
- Assess total body posture and provide education and exercises to improve alignment
- Goal is to maximize strength and focus on safety awareness.
Occupational Therapy:
- Train patient in self-care techniques and ADLs
- Employ strategies and evaluate for assistive devices to maximize independence and reduce assistance from caregivers
- Aid in maintaining and improving joint range of motion, muscle strength, endurance, coordination, dexterity
[remark]content[/remark]
Precautions: Fall Risk