Admission Details for Patient: David Lewis (2442)
Gender: Male Age: 39
Marital Status: Married Religion: Calvinist Methodist
Occupation: Shoemaker
Address: Llanaber, Merioneth
Date of Admission: April 21, 1875
Date of Death: August 5, 1875
Cause of Death: Debility/Softening of the brain
Disease: Dementia
Supposed Cause: Domestic affliction
Medical Certificate:
He has an idiotic look and seems timid and apprehensive and says that his (illegible) is broken but when examined there appears nothing the matter with it. He does not sleep well nor does he care anything for his children. He passes his motions and urine without any regard to his dress. By Mrs Edwards: That he is abusive to his wife and one day he threatened to strike her with a tree which was growing in front of the house and that one day he put his coat on front-backward and when told of it he did not seem to comprehend his mistake. Hugh James Lloyd, Surgeon, Barmouth.
Approximate duration of present attack: 9 months
Number of Previous Attacks: 0
Number of Previous Admissions: 0
Number of Subsequent Admissions: 0
Total Number of Admissions: 1
Relatives affected:
Epileptic: No
Suicidal: No
Dangerous: No
Clean Habit: No
Food Refusal: Appetite voracious
Sleep Habit: Bad
Destructive Habit: No
Disposition: Sober as a rule, sometimes drank to excess
Education: Bad
Physical/Mental State at Examination: Previous bodily health robust. On admission very feeble, free from bruises. Above middle size, phlegmatic temperament. Somewhat emaciated, compete alopecia. Tongue very clean and very tremulous. Bowels open. Good appetite. Hearts impulse feeble, pulse accelerated. In a condition of complete mental vacuity. Seemed in great terror and apprehension that someone would injure him. When asked a question he attempts to reply but fails either as a consequence of forgetfulness of speech or inability to letter the words. There is a great deal of muscular tremors and debility. The tongue trembling violently when with difficulty protruded and he totters in walking. First indications occurred eighteen months ago when he lost three children from Scarlet Fever. No one would enter the house and this made him very low and depressed. Continued work until 9 months ago when, the depression and debility increasing, he became unable to work.
Current Diagnosis: Unspecified Dementia (F03)
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