26th Case of the Week Due 7/8/19, by 1pm EST
Medicare IRF, Reviewed 6/24/19
CCR6. Hospital admitted s/p fall w/ LOC while trying to ambulate to bathroom. Hypotensive/Bradycardia started on Dopamine gtt. CT: C4-C5 Spinous process fx. MRI: Bright signal intensity of the cord on STIR sequence C3-4 to C7 - T1. C2-T1 posterior decompressive laminectomy w/ instrumentation 4/9. Trach/Peg placement 4/18. Post op course influenza & MSSA PNA. Expected DCP: Home w/ family. Expected DC Date: 06/27/2019. PMH: Cardiac Dysrhythmia, HTN, Anxiety, Bipolar Disorder. PLOF/ Living Situation: Lived w/ husband/family. Home Setup: 1 level house w/ 0 STE, 1 SH, ramp entry. Behavioral Health: Psych consult: Anxiety, Depression. Advanced Directive/Living Will: Full code. Service requested for: IRF- Medical/PT/OT/SP. *Skilled Medical Needs: Stable w/Trach #8, Vent Fi02 at 0.4. Vent dep. Urethral cath. Peg tube w/TF of Peptamen 95ml/hr. Wounds: Sacrum stage 4 debridement wkly 6.0x4cm unstageable, Tx: Collagenase QD. Rt IT 3.8x3 DTI, Tx: Foam dressing. Rt Scapula 5x2.0 unstageable, Tx: Dakins wet to dry dressing from stage 2, Tx: Silvadene QD. Lt Scapula 5.0x1.0 unstageable, Tx: Dakins wet to dry dressing from Collagenase QD. Med Management: Pain Tylenol 650mg Q4 PRN & Tramadol 50-100mg PRN. 6/13 Daily weaning trach collar if tolerated. Trach collar trials x 5.5 hr w/divided breaks. *Current Mental Status: AAOX3. Dementia Score: N/A *Bed Mobility: Dep (Unchanged). *Ambulation: N/A d/t tetraplegia ft (No Update). WC mobility trialed chin control drive forward, able to drive forward w controlled stopping, fatigues easily, unable to make turns. *Transfers: Dep. *Stairs: N/A d/t Tetraplegia steps (No Update). *Bathing UB: Dep. *LB: Dep. *Dressing UB: Dep. *LB: Dep. *Toileting: Dep. *Toilet transfers: Dep. *Speech Tx: Tolerated speaking valve x 15 mins, oriented w/moderate verbal cuing. Pt tolerating at least 3hrs of therapy 5days/wk. All functions unchanged.
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