David Lewis (2442)

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)

Case Notes

1875 Apr 22 - Slept well last night in No 7 ward.

Complete incoherence.

Eats well.

Wetted his bed.

Not quite so timid and is able to appreciate kindness.

Was taken out to the Airing Court.

Apr 23 - Just the same. Losing his timidity. Dirty in his habits, very feeble, tottering considerably in his gait.

May 1 - A good deal worse. Muscular tremor very much increased after a short interval of apparent amendment.

Unable to protrude his tongue.

Lost all control over bladder and rectum and must be changed several times a day.

Gets bread and milk at 11 o'clock and beef tea. Not yet confined to bed though unable to walk without assistance. Sitting all day in No 5 Ward.

Sleeping and eating well. May 11 - Somewhat feebler since last date - Was today attacked by vomiting which soon ceased.

Placed in bed.

18 - Mental condition worse. Dirty habits, has been made to get up since in order to prevent bedsores.

Eats all that is offered him.

25 - Was today placed upon a horseshoe water cushion although bedsores were healing under the application of Ung. Zinci w Plumbi. Dirty in his habits.

June 4 - Bedsores almost healed.

Mental and bodily condition the same. Completely demented.

July 26 - Gradually getting more feeble.

For the last month has been lying on water bed.

Bedsores have again formed there being two large ones on left buttock sloughing.

Ordered Linseed Meal poultices.

Eats his food freely.

His condition is very like that of John Moore.

About the beginning of the month he had a slight attack of paralysis of left side which passed away in a couple of days. He was convulsed for a couple of minutes and appeared to have been for a short time insensible.

Utterly fatuous in mind and very dirty.

Medications/Treatments: Zinci w Plumbi (zinc with lead) (ointment for bedsores), Linseed meal poultices, Horse shoe water cushion/Water bed

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