Client Note (Lindsey)
Lindsey
Client ID 059
- Name
- Lindsey
- Primary Diagnosis
- Spina bifida
- Insurance
- Medicaid
- Referring Physician
- W. Lopez, MD
- Age
- 26
- Gender Identity
- Female
- Pronouns
- She/her/hers
- Race/Ethnicity
- White
26yo WF with spina bifida, diagnosed at birth. Received OT/PT throughout childhood. Does not currently receive therapy services. Past medical history includes club feet with corrective surgeries, tethered cord release, bladder augmentation surgery, cystostomy surgery, and R Humerus fx (managed conservatively).
Marital status:Single
Primary language:English
Current level of function:Modified independent with BADLs and IADLs except assist from parents for meal preparation, financial management, and transportation. Ambulates mod I with rollator for long distances and cane for short distances.
Employment/work/school:High school education. Works part-time as a barista. Work duties involve prolonged standing and occasional lifting up to 15 pounds.
Play/leisure/interests:Enjoys reading, listening to music, and doing crafts.
Environmental factors:Lives with parents in two-story house. 1 STE, B handrails, 13 steps to 2nd floor with chair lift. Walk-in shower (2” ledge) with shower curtain, shower chair, handheld shower hose. Standard height toilet, no grab bars.
Trimethoprim-sulfamethoxazole