Client Note (Andy)
Andy
Client ID 049
- Name
- Andy
- Primary Diagnosis
- Progressive supranuclear palsy
- Insurance
- Medicare
- Referring Physician
- J. Wu, MD
- Age
- 70
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- White
70yo WM with progressive supranuclear palsy, initially diagnosed 5 years ago after developing recurrent posterior losses of balance and reduced volume of speech. Currently receives outpatient OT, PT, and SLP services. Also has a history of type 2 diabetes, diabetic coma, kidney disease, dry eye disease, dry mouth, glaucoma secondary to diabetes, and Charcot foot with foot reconstruction surgery.
Marital status:Married 49 years
Primary language:English
Current level of function:Requires partial assist for ADLs. Ambulates with rollator. Requires substantial assist for IADLs. Does not drive. Wife reports client can be overconfident at times and requires supervision for safety.
Employment/work/school:College education (law degree). Managed family dairy farm until elected youngest member of state legislature. Worked as a radio talk show host after public service, but is now retired.
Play/leisure/interests:Enjoys participating in adaptive sports program activities, including orchestra (clarinet and percussion), bowling, fishing, golfing, and archery. Still keeps up-to-date on politics through watching and reading the news every morning. Continues to be involved in advocacy, especially related to agricultural policies, but reports typing has become difficult.
Environmental factors:Lives with wife in a two-story house. 3 STE with custom ramp, no handrails. Bedroom, bathroom, living room, dining area, and kitchen on first floor. Zero-entry shower with shower chair, handheld shower head, grab bars, and bedside commode over toilet. Mainly uses rollator but also owns a FWW and U-Step walker. Occasionally uses a standard wheelchair in the community. His adult son lives locally and provides assistance intermittently.
None
Levadopa
Lyumjev
Lantus
Tovistatin
Pilocarpine
Supplements (Vitamin D, B12, Zinc, Probiotics, Berberine, Magnesium)
MRI: Marked atrophy in midbrain ("hummingbird sign") and mild cortical thinning in frontal lobe, highly suggestive of Progressive Supranuclear Palsy