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Client Note (Gloria)

Gloria

Client ID 052

Name
Gloria
Primary Diagnosis
RLE AKA
Insurance
Medicare
Referring Physician
T. Jones, MD
Age
81
Gender Identity
Female
Pronouns
She/her/hers
Race/Ethnicity
White

81yo WF with RLE AKA due to complications from DVT 18yrs ago. Hospitalized in acute care for 8 days. D/c to inpatient rehabilitation x 2wks followed by outpatient PT x 1yr.

Marital status:Married 61 years

Primary language:English

Current level of function:Modified independent for all ADLs/IADLs, including driving with left foot accelerator. Ambulates with RLE prosthetic.

Employment/work/school:College education. Retired office manager for a real estate office. Currently volunteers 3 days a week at the hospital gift shop where she attended inpatient rehabilitation. Her husband also volunteers at the hospital managing a library cart and visiting with patients.

Play/leisure/interests:Enjoys participating in adaptive sports program activities including billiards, bowling, boccia, archery, trap shooting, kayaking, fishing, and golf. Also likes completing jigsaw puzzles and traveling.

Environmental factors:Lives with husband in one-story house with 1 STE, no handrails. Walk-in shower (2” ledge) with shower curtain, tub transfer bench, grab bars, handheld shower hose. Raised toilet seat with grab bars.

Warfarin
Gabapentin

Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.