19th Case of the Week Due 12/27/18, by 1pm EST

Emblem Commercial SNF, Review 11/05/18

CCR3. 63 y/oM. Admitting Diagnosis: Fall. Brief Clinical Course: Admitted 10/11 presents S/p fall d/t leg weakness. CT head-No acute intracranial hemorrhage. MRI brain-No evidence of mass, few chronic small Lt frontal infarcts. Acute stroke clinically unlikely, as symptoms are dysarthria and bilateral leg weakness. Extrapyrimal and movement disorder likely d/t antipsychotic meds. Target LOS 18 days (TGD 11/03/18) provided to facility based on DRG number: DRG 312. Expected DCP & date: TBD, unknown if safe d/c. Number of Skill Days used /100 days: 24. PMH: Syncope/collapse, HTN, DM, schizophrenia, CVA, gout, obesity. Never smoked, no alcohol or drug use PLOF: Independent, cane. ADL and self-care needs assistance, pt working to get his sister as his HHA. Home Set Up: Lives alone in 4 STE apartment, coop w/ elevator.
*Skilled Medical Needs: medical and medication management. Meds: Aspirin 81mg QD Prophylaxis, Atorvastatin calcium 40mg Q HS for HDL, Benziropine Mesylate 0.5mg Q Daily Anti tremor, haloperidol 2mg HS, Metoprolol Succ ER 50mg QD HTN, Insulin sliding slide daily. VS 97.2, 18,72104/63. BS 2220mg/dl. VS 10/26/18 138/80, 97.4,18,98% RA BS 180mg/dl.
*Current Mental Status: AAOX3
*Bed Mobility: CGA to sup A (Improved)
*Ambulation: 30ft. Mod A to 60ft. Min A (Improved)
*Transfer: Mod A to CGA (Improved)
*Stairs: 4 steps Max A to 6 steps Mod A (Improved)
*Bathing UB: Max A to Mod A (Improved)
*LB: Max A to Mod A (Improved)
*Dressing UB: CGA to SBA (Improved)
*LB: Mod A to Mod A (unchanged)
*Toileting: Max A to Min A (Improved)
*Toilet Transfers: Max A (Unchanged)
*Speech Tx: none. Diet: Consistency Carb diet, regular texture, Thin Consistency.
OT Goal: Continue to work on ADLs until 11/20/18, pt cooperating.


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