6th Case Of The Week- Medicare Case; Due 9/20/18, 1pm EST
Clinical Review: CCR2.
Brief Clinical Course: 73yo F admitted to acute setting with Lt leg pain, instability, and swelling d/t fall. Lt Leg X-ray showed broken Tibia. Dx Lt Transverse Tibia Shaft Closed Fx. Surgery Lt Leg External Fixation Lt.
Target LOS: 21 days.
Expected DCP: DC to home with HHC (SN/PT/HHA) to assist with ambulation, balance, strengthening, transfers, ADLs.
Number of Skill Days used out of 100 days: 17 eviCore days.
PMH: HTN, OA, DM.
PLOF: Independent with ADLs/IADLs, drives.
Home Set Up: Lives w/daughter and son-in-law in ranch level house w/ basement, 3STE, main bed/bath main floor. Daughter and son-in-law works 8 hrs a day, will assist once off work.
*Skilled Medical Needs: Medication Management with Asa 81mg PO daily, Tylenol PRN; increased Ultram 25mg PO q6h to 50mg PO q6h for increased Lt leg pain (9/10 before, 3/10 after), V/s every shift, monitor surgical site for infection.
*Current Mental Status: A&Ox3.
*Ambulation: 25ft Mod A, RW, unstable d/t leg pain (improved w/distance).
*Transfers: Mod A (improved), Bed Transfers: Min A (unchanged).
*Stairs: NT.
*Bathing: UE SBA (unchanged), LE Mod A (improved).
*Dressing: UE SBA (unchanged), LE Mod A (improved).
*Toileting: Min A (improved).
*Toilet transfers: Mod A (improved).
*Speech Tx: NA.
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