16th Case of the Week Due 11/22/18, by 1pm EST

LTAC Medicare Review 10/25/18

CCR1. 61yo M. Current Mental Status: A&O x1. Admission to LTAC: 10/19/18. Expected DCP: SNF tentatively 11/9/18. Reason/Diagnosis for Acute Admission: Fever/Sepsis/UTI. Significant PMH: Huntington's Dz, dementia, PAD, thrombocytopenia. Brief acute facility stay summary/significant clinical event: presented from nursing home due to fever. Patient is post-op Lt Leg hematoma evacuation secondary to AAA Repair with leg bypass graft (9/30/18). Language: Nonverbal at baseline/Greek. Fever likely secondary to UTI vs. LLE surgical site infection. IV Vanc/Zosyn. LLE swelling s/p hematoma evacuation 9/11/18 -US left lower extremity 6.4 cm x 1.7 cm complex fluid collection. Ventilator Information: N/A. Date of tracheostomy: N/A.

*IV Medications & IV fluids being given in LTAC: Vanc 1500mg Q8H (at least 19 days left.)

*Physical Findings: No CXR at this time. Recent Vital Signs and Significant Laboratory Results: 154/72, 59, 17, 97.6, 98%, Hgb – 10.6, WBC – 6.9 (improved Initial Review WBC 8.4), Cr – 0.51.

*Wounds: LLE - 4 x 1 x 1 cm. Full thickness skin loss, may extend down to underlying fascia. Wound vac applied, changes MWF.

*Nutrition: Oral diet.

*PLOF: Total. Mod I per Initial Review.

*Prior Living Situation: Lives with spouse house unspecified. 2SH, 1+1 STE, bed/bath 2nd floor per Initial Review.

*Social Hx: Noncontributory. Behavioral Health: Noncontributory. Advanced Directive/Living Will: Not provided.

*Current Level of Functions: Total. Speech Tx: Eval pending.

PT/OT provided changes to Functional Skills for improvements/gains.



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