9th Case of the Week, Commercial (HIP) SNF, Due 10/11/18, by 1pmEST

CCR#1. Brief Clinical Course: 81 y/o F. Admitting Diagnosis: SOB, dysphagia. Admitted 8/31/18 with functional decline, unsteady gait, & depression. Two blood transfusions during stay. Endoscopy performed d/t dysphagia & esophageal cancer, gastric lesions & hiatal hernia noted.

Target LOS: 21 days (tx goal date: 09/28/2018) provided to facility based on DRG number: NA.

Expected DCP: does not plan to return to home, plans to be d/c to another nursing home, d/c date TBD.

Number of Skill Days used out of 100 days: 10 eviCore days including this review.

PMH: COPD, esophageal cancer, hypothyroidism.

PLOF: Independent with BADLs, wears adult diapers & changes herself. She reports decreasing ability to shower, used 3 point cane to ambulate in & outdoors up to about 1 block. she states she does not receive assistance from her daughter & plans to be d/c to another LTC facility.

Home Set Up: Lives in the basement apartment of her daughter's home w/ 6 steps down to enter.

Skilled Medical Needs: alprazolam .5mg tab, amlodipine 5mg tab, ipratropium-albuterol inhalation, levothyroxine 25mcg tab, omeprazole 20mg cap, sertraline 50mg tab, v/s (98.7, 65, 20, 129/59, 94%).

Current Mental Status: AAOx3.

**Ambulation: 75ft, minA w/ RW. bed mobility: minA. (Declined Initial Review)

**Transfers: minA. (Declined Initial Review)

**Stairs: DNT. (Not provided Initial Review)

**Bathing: minA. (Not provided Initial Review)

**Dressing: UB: set-up A. LB: minA. (Not provided Initial Review)

**Toileting: minA. (Not provided Initial Review)

**Toilet Transfers: minA. (Not provided Initial Review)

**Speech Tx: NA. Diet: mechanically altered chopped texture. (Speech/swallow eval performed Initial Review)

Pt is participating in therapy 1 hr/day 5 days/wk.


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