33rd Case of the Week Due 2/6/20, by 1pm EST, Medicare HF
Review Completed 1/27/20. CCR1. Brief Clinical Course: 60yoM Admitted 1/14/20 Dehydration, Acute Complicated UTI, Fatigue, Failure to Thrive, Dysphagia. Target LOS 18 days provided to facility based on DRG 689 (MDC 11) Kidney & UTI w/ MCC. TGD: 2/10/2020. Expected DCP: Home w/family support. Expected DC date: 2/15/20. Number of Skill Days used prior to current review/100 days: 10. PMH: PE, Lung Cancer, HLD, and HTN. PLOF/ Living Situation: Independent functional mobility, ADLs w/ RW. Home Setup: Lives alone in apt bldg., 5flr, elevator access, 7 STE. Behavioral Health: Not provided. Advanced Directive/Living Will: DNR. Service requested for: SNF2. *Skilled Medical Needs: Teach/Monitor for S/sx Infection, Educate on bladder emptying/control, Safety/Fall Precaution, Monitor for Fatigue/Failure to Thrive. V/S 1/26/20: BP 126/74 P 105 T 101.4 R 18 O2 SAT 96% RA. Medication Management: Levaquin 250mg PO 10 days Start 1/26/20 UTI, Tylenol 325mg 2 tabs Q6hrs PRN Pain, Amlodipine 2.5mg Daily - HTN, Apixaban 5mg Q12hrs - PE w/o acute COR Pulmonale, Atorvastatin 10mg HS –HLD.*Current Mental Status: AAOX4. Dementia Score: Not Provided. *Bed Mobility: ModA --> MinA (Improved). *Ambulation: 5ft ModA w/ 2 WW--> 25 ft ModA w/ 2 WW (# Ft Improved) rest periods every 5-10 ft. *Transfers: ModA --> MinA (Improved). *Stairs: DN --> DNT weakness/fatigue (Unchanged). *Bathing UB: (No Update); *LB: (No Update). *Dressing UB: MinA --> CGA (Improved); *LB: MaxA --> ModA (Improved). *Toileting: ModA (Unchanged). *Toilet transfers: ModA --> MinA (Improved). *Speech Tx: Diet: Regular, thin liquids. Therapy working towards meeting goals; pt able to participate in PT/OT/SP 2-3 hrs/day, 5 -6 days/wk.
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