5th Case of the Week--Standard Medicare; Due 9/13/18, by 1pm EST
Clinical Review CCR 1. PHI verified via fax.
Brief Clinical Course: 83 y/o M admitted w/Rt sided weakness d/t sudden onset of right sided hemiparesis and facial droop. MRI positive for stroke. tPA given, Lt MCA mechanical Thrombectomy. Patient with aphasia, A&O x4 w/ periods of confusion.
PMH: Hypothyroidism, BPH, HLD, Dementia, HTN, new onset of A-fib, and obesity.
PLOF: Independent with ambulation, ADL’s and driving. Lives alone in a split level home with 0 STE, 6 steps in home, bed and bath on main level.
CLOF: Continues with Rt sided weakness, Ambulation: 20ft w/Mod A 2WW, Mobility: Supine to sit Mod A, Transfers: Stand to sit Min A, Bathing: UB SBA Lt side, Min A Rt side; LB Min A, Dressing: UB SBA Lt side, Min A Rt side; LB Min A, Toileting: Min A. Pt participating in therapy.
Speech Therapy: Regular diet with thin liquids per Speech Consult.
MD would like a SW/Nutritional Consult setup this week.
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