Client Note (Phillip)
Phillip
Client ID 057
- Name
- Phillip
- Primary Diagnosis
- R CVA
- Insurance
- Medicaid
- Referring Physician
- M. Korman, MD
- Age
- 44
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- White
44 yo WM with R CVA sustained 5 years ago. Hospitalized x 1wk after c/o L-sided weakness. D/c to inpatient rehabilitation x 3wks followed by outpatient OT/PT x 1yr. Does not currently receive therapy services. History of HTN.
Marital status:Married 15 years
Primary language:English
Current level of function:Modified independent for BADLs, partial assist for IADLs provided by wife. Does not drive. Ambulates without assistive device.
Employment/work/school:High school education. Worked as car salesman prior to stroke, currently unemployed.
Play/leisure/interests:Enjoys participating in adaptive sports program activities including bowling and billiards. Regularly attends son’s basketball games and school plays.
Environmental factors:Lives with wife and 12 yo son in one-story house with 1 STE, R handrail. Walk-in shower with glass door, handheld shower hose, shower chair, grab bars, and long-handled sponge. Standard toilet height with toilet safety frames.
Baclofen
Losartan