Client Note (Mitch)
Mitch
Client ID 062
- Name
- Mitch
- Primary Diagnosis
- Progressive cerebellar degeneration post-TBI
- Insurance
- BCBS
- Referring Physician
- M. Alexander, MD
- Age
- 59
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- White
52yo WM with progressive cerebellar degeneration post-TBI from MVA 41 years ago, the summer after graduating high school. Sustained 4hr loss of consciousness and underwent craniotomy and cranioplasty. Hospitalized in acute care for 1 month with d/c home. During college years later, he noticed decreased balance and loss of coordination and was diagnosed with progressive cerebellar degeneration. Past medical history includes torn medial meniscus in R knee.
Marital status:Single
Primary language:English
Current level of function:Modified independent with all ADLs/IADLs using rollator, mobility scooter, or manual wheelchair. Drives independently.
Employment/work/school:College education. Part-time records clerk for the county. Work duties involve prolonged sitting at a desk and occasionally lifting up to 20 pounds.
Play/leisure/interests:Enjoys participating in adaptive sports program activities including cycling and rowing. Regularly attends church and is involved in church events.
Environmental factors:Lives with two roomates in first floor of condo with no STE. Tub/shower combo with flexible shower hose, grab bars, and tub transfer bench. Standard toilet, no grab bars.
Ibuprofen PRN