1. The patient, a XX-year-old white male, was referred for a mental health consultation due to yelling out and apparent confusion. He had a history of multiple medical issues including a recent "large watershed stroke" affecting two areas of his brain. 2. On examination, the patient was restless, dysarthric, tangential, and showed impaired insight, judgment and orientation. It was assessed that he was more confused than initially thought. 3. Recommendations included continuing the patient's antidepressant to aid appetite, increasing his pain medication, and providing memory aids and a consistent routine to accommodate his vascular dementia and fluctuations in functioning.

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Mental Health Consultation
Patient Name: watershed infarct Facility: XXXX
Date: 12-10-13
History and background Information can be found elsewhere in this chart and will not be
repeated here. Please see discharge summary from XXXX dated 12-3-13.
Reasonfor Referral: XX-year-old, white, xx, male… I was asked to evaluate him “He yells
out…staff think its pain…he takes Remeron without an indication”. He was admitted from
XXXX on 12-3-13 where he had been treated initially for multiple myeloma with a bone marrow
transplant but ran into many complications including: cardiogenic shock, Atrial- Fibrillation,
aspiration pneumonia, pneumothorax, orthostasis, and a “large watershed stroke on the frontal
and right occipital between middle and anterior cerebral artery territories”.
Current Medications: Remeron 30mg qhs, Metoprolol, acyclovir, lactobacillus acidophilus,
loperamide, Zofran, Oxycodone 2.5mg q4hr prn, Pepcid.
Medical History: Stage III Chronic Kidney Disease, Congestive Heart Failure, Hypertension,
Multiple Myeloma, Coronary Artery Disease, Atrial-Fibrillation, Stroke, DVT, Dysphagia,
Obesity, history of: MI, bladder tumor, aspiration pneumonia, pneumothorax, orthostasis,
Mental Status Exam: I found him in bed awake and alert. He was a thin nearly bald man who
must have lost a lot of weight in the past few months given his diagnosis of obesity. He was
cooperative and engageable but kept his arms crisscrossed over his chest, was restless, moving
about a lot and spoke in a dysarthric whisper. He perseverated a bit on slightly odd questions;
“Do you think 4 weeks is unrealistic to rehab and go home?” His speech was somewhat
circumstantial and tangential with frequent paraphasic errors. His affect was constricted and
inappropriate at times. He denied depression or anxiety. He did say “I never sleep” He exhibited
some facial flattening. He was right handed. His speech comprehension seemed OK. He
struggled to provide me with the correct year and month and he gave the place as” xxxx” and
though he was here “a day or two”. His insight and judgment was impaired. He did c/o of pain
in the area of his decubitus ulcer.
Findings and Recommendations: Staff are probably correct about the cause of his yelling. He
yells when he is feeling pain associated with his decubitus ulcer. He is much more confused than
most people think on first contact with him. On the next page, I have included a slide describing
watershed dementia taken from my in-service on vascular dementia. You can see from a quick
glace just how terribly damaging a watershed infarct is.
I suspect the Remeron was started to increase his appitite before he was started on the PEG
feedings. He has clearly lost a lot of weight.
1. We should keep him on the Remeron for now. Revisit this when we get to know him
better. A different antidepressant maybe more helpful if we see S/S of PSD.

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2. Would increase his oxycodone and change from prn to routine. Tell him he can refuse if
he does not feel he needs it. This will provide better pain coverage. He is a bit too
confused to ask for a prn.
The following is the part of the description from his X DC summary that makes the most sense:
“right (side)…between middle and anterior cerebral artery territories”. Therefore, there is
damage to the part of the brain which mediates functions such as: non-verbal memory, planning
ability, integration of senses, orientation in space, motivation, social judgment which led to
symptoms such as: post stroke apathy, unawareness of deficits, fluctuations in arousal, passive
opposition, failure to rehabilitate and decreased vitality …to name just a few.
3. Provide him with memory and orientation aides such as: signs, large clocks, calendars
and lists.
4. Establish a predictable and consistent daily routine for him. Keep him busy with simple
tasks but not excessively stimulated. Track his daily fluctuations in arousal and schedule
the most demanding activities when he is typically at peak arousal levels. Schedule
frequent rest periods but no naps throughout the day.
5. The further into isolation and dependency stroke patients retreat, the worse the prognosis
and vice versa. Higher levels of activity and independence lead to a better prognosis for
recovery. Therefore, it is important to keep him actively engaged in treatment and facility
activities.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist