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Elderly woman in a hospital bed, wrapped in a patterned shawl, looks directly ahead as a nurse works in the background.

🩺 Dummyfall: Frau Klara Neumann (79 Jahre) Allgemeine Daten Name: Klara Neumann Alter: 79 Jahre Geschlecht: weiblich Wohnsituation: lebt allein in einer kleinen Mietwohnung im 3. OG ohne Aufzug Soziales Umfeld: eine Tochter (wohnt 60 km entfernt), Nachbarin unterstützt gelegentlich Pflegegrad: Antrag gestellt, noch kein Gutachten erfolgt Einrichtung: Aufnahme auf einer Akutstation (Innere Medizin) nach notfallmäßiger Einweisung Medizinische Diagnosen Diabetes mellitus Typ 2 (seit 12 Jahren), HbA1c zuletzt 8,4 % Arterielle Hypertonie Chronische Herzinsuffizienz NYHA II–III Harnwegsinfekt (akut) Sturzneigung, nach aktuellem Sturzereignis Adipositas (BMI 31) Arthrose in beiden Kniegelenken Leichte kognitive Einschränkungen (Verdacht auf beginnende Demenz) Aktueller Anlass der Aufnahme Frau Neumann wurde vom Rettungsdienst nach einem Sturz in der Wohnung in die Klinik gebracht. Sie lag laut eigener Aussage etwa 2–3 Stunden am Boden, bevor die Nachbarin sie fand. Symptome bei Aufnahme: Fieber 38,6 °C Dysurie, übelriechender Urin Starke Schmerzen im rechten Knie Verwirrtheit (zeitliche Desorientiertheit) Dehydrationsanzeichen Aktuelle Medikation Metformin 1000 mg 1–0–1 Ramipril 5 mg 1–0–0 Bisoprolol 2,5 mg 1–0–0 Furosemid 20 mg 1–0–0 Ibuprofen 400 mg bei Bedarf Antibiotikum (Cefuroxim i.v. 2× täglich) Insulin nach Schema bei BZ > 180 mg/dl Ressourcen Kann mit Gehstock kurze Strecken laufen Motiviert, wieder zurück nach Hause zu können Gute kommunikative Fähigkeiten im klaren Mehr sehen

#medical #hospital #elderly

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