6 min
Comprehensive Medical Report
Age: 68 years
Source: Consolidated records and family summaries (2020β2025)
Executive Summary
The patient is a 68-year-old male with multiple chronic and progressive neurological, cardiovascular, and systemic conditions. Chief diagnoses include Lewy Body dementia with amyloid angiopathy, recurrent strokes, and epilepsy. He has a history of type II diabetes mellitus (currently in remission), severe sleep apnea, and other comorbidities. Functional decline since 2020 has been severe, leaving him fully dependent on 24-hour nursing care.
Recent Medical Course (2020β2025)
- 2024β2025: Multiple falls resulting in femoral fractures and surgical intervention.
- 2023β2024: Returned home after 13-month institutional stay. Treated successfully for severe pressure ulcers; PEG tube removed.
- January 2022: Aspiration pneumonia (3/5 lung lobes affected), hospitalization required.
- November 2021: Multiple strokes with seizures; ICU admission.
- June 2020: Initial cerebrovascular event with rapid cognitive decline, memory loss, and social withdrawal.
Current Functional Status
- Mobility: Severely limited, requires assistance for transfers and ambulation.
- Nutrition: History of dysphagia; requires careful monitoring to prevent aspiration.
- Cognition: Severe impairment; minimal speech; no decision-making ability; passive participation in physiotherapy.
- Independence: Fully dependent on caregivers, requiring continuous supervision.
Ongoing Care and Monitoring Needs
- Neurological monitoring for seizures and stroke recurrence.
- Swallowing and aspiration risk management.
- Passive physiotherapy for mobility preservation.
- Infection prevention given aspiration pneumonia history.
- Fall prevention due to cognitive and motor impairment.
- Polypharmacy management with regular medication reviews.
- Social stimulation and speech therapy (limited benefit but considered for quality of life).
Prognosis and Planning
The clinical trajectory is progressive and incurable. The care plan prioritizes:
- Comfort in a familiar environment.
- Prevention of secondary complications.
- Supportive palliative and end-of-life care.
Current Medications
- Lacosamide (Vimpat) 100 mg, TID.
- Carbidopa/Levodopa (Sinemet) 25/100 mg, QID.
- Bisoprolol 1.25 mg daily.
- Atorvastatin (Torvast) 40 mg nightly.
- Escitalopram (Cipralex) 10 mg nightly.
Primary Medical Conditions
Neurological
- Lewy Body Dementia with Amyloid Angiopathy: Diagnosed 2021, progressive cognitive decline, amyloid angiopathy confirmed on MRI.
- Recurrent Strokes: Multiple cerebrovascular accidents (2020, 2021, subsequent subclinical events), linked to hypertension and amyloid angiopathy.
- Epilepsy: Onset in 2020; controlled with current therapy.
Cardiovascular
- Hypertension: Longstanding, poorly controlled, contributing to cerebrovascular disease.
- Left Atrial Dilation: Noted on echocardiogram.
Endocrine
- Type II Diabetes Mellitus: Diagnosed 2020, previously insulin-dependent, currently in remission.
Respiratory
- Severe Sleep Apnea: Previously CPAP-managed, discontinued by 2023.
- History of Subglottic Stenosis: Required surgical intervention.
Ophthalmological
- Age-Related Macular Degeneration: Right eye vision 4/10; left eye 1β2/10 with macular atrophy and corneal lesions.
Gastrointestinal
- GERD (resolved): Previously symptomatic, now managed conservatively.
- History of Dysphagia: PEG removed after recovery.
Urological
- Benign Prostatic Hyperplasia with Incontinence: Partial prostate ablation; ongoing urinary issues.
Orthopedic
- Chronic Back Pain/Arthritis: Previous interventions, not actively treated.
Neuropsychiatric
- Depression: Documented history; not actively treated given advanced neurological state.
Summary Statement
This is a case of advanced neurodegenerative disease complicated by multiple systemic comorbidities. The focus of care remains palliative: maintaining comfort, preventing complications, and preserving dignity. The family is actively involved in care decisions and maintains detailed medical records.