29th Case of the Week Due 10/10/19, by 1pm EST

IRF, Medicaid Reviewed 9/30/19
CCR3. Brief Clinical Course: Admitting Dx: Acute Ischemic Lt MCA CVA. Admitted 9/4/19 found on floor x4 days unable to speak/move, rt sided weakness. A Fib w/ RVR, Cardizem gtt & changed to Atenolol. 9/11/19 Ativan pulled out IV & pulling at cords for monitors/agitation. CIWA-Clinical Institute W/drawal Assessment for + drug, ETOH screen. Hypotension 9/11/19. CT Head concerning for Lt MCA thrombus. CTA Neck 70-80% luminal narrowing of Lt ICA. + drug screen ETOH, opiates, cannabis. Physical Findings: Rt sided weakness. Expected DCP: 10/7/19 D/c to SNF for Skilled Med needs. PMH: A Fib, HTN, HLD. Coronary Angioplasty. PLOF/ Living Situation: I w/ ADLs, ambulation. Home Setup: Lives alone in 1st FL apartment, working. Behavioral Health: Major depressive disorder. Hx of suicidal ideation. Family reports problems w/ADHD & maintaining a job. Advanced Directive/Living Will: Full code. Request: IRF. *Skilled Medical Needs: Fall 9/27/19 w/injury & pain. X ray Rt shoulder, spine, pelv/rt hip unremarkable. PT/OT stroke rehab to improve RLE strength, ambulation, sitting/standing balance & endurance to maximize independence w/functional mobility. Foley catheter monitoring. Meds: Apixaban, ASA, Atorvastatin, Clopidogrel, Ergocalciferol, Lasix, Lisinopril, Paxil, Seroquel, Norco *Current Mental Status: Communication deficits, orientation not provided. Dementia Score: Not Provided. *Bed Mobility: MinA (Improved). *Ambulation: 40-70 ft ModA w/ RW & W/C follow -> not provided. *Transfers: ModA (Improved). *Stairs: Not Provided. *Bathing UB: Not Provided; *LB: Not Provided. *Dressing UB: MinA (Unchanged); *LB: MaxA (Improved). *Toileting: Not Provided. *Toilet transfers: Not Provided. *Speech Tx: Mod to Severe aphasia/apraxia w/severe dysarthria. Min to mild oral dysphagia, 9/30/19- Gen/thin. # of therapy hrs/day not provided.

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