Client Note (Bubba)
Bubba
Client ID 063
- Name
- Bubba
- Primary Diagnosis
- R CVA
- Insurance
- BCBS
- Referring Physician
- H. Haynes, DO
- Age
- 56
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- White
56 yo WM with R CVA sustained 13 years ago. Hospitalized x 1wk after c/o L-sided weakness. D/c to inpatient rehabilitation x 2wks followed by outpatient OT/PT x 4 months. Does not currently receive therapy services. History of HTN.
Marital status:Single
Primary language:English
Current level of function:Independent with all ADLs/IADLs, including driving, no assistive device.
Employment/work/school:High school education. Full-time transportation specialist for paratransit bus. Work duties involve prolonged sitting and frequent lifting up to 20 pounds.
Play/leisure/interests:Enjoys relaxing at home and going on family vacations.
Environmental factors:Lives alone in one story house with 1 STE, no handrails. Walk-in shower (2” ledge) with shower curtain and fixed shower head. No DME.
Lisinopril