Client Note (Corey)
Corey
Client ID 045
- Name
- Corey
- Primary Diagnosis
- SCI
- Insurance
- Medicaid
- Referring Physician
- N. Kent, MD
- Age
- 39
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- White
39yo WM with ASIA D SCI (C7, motor incomplete) sustained 7 yrs ago from MVA. Underwent spinal decompression and fusion. Hospitalized for 1 month in acute care. D/c to inpatient rehabilitation where he stayed for 4 mos. Received outpatient OT/PT for 15 mos.
Marital status:Single
Primary language:English
Current level of function:Modified independent for ADL/IADLs with adaptive equipment PRN, including driving with hand controls. Ambulates with NBQC.
Employment/work/school:High school education. Currently unemployed.
Play/leisure/interests:Enjoys participating in adaptive sports program activities, including billiards, pickleball, and wheelchair rugby. Follows college football and basketball, meeting with friends regularly to watch the games.
Environmental factors:Lives alone in a first floor apartment with 1 STE, no handrails. Tub/shower combo with shower curtain, handheld shower head, tub transfer bench, nonskid mat, grab bars. Raised toilet seat with grab bars. Uses built-up utensils. Has one brother who lives across the country and cannot help routinely.
Gabapentin
Baclofen