Client Note (Scott)
Scott
Client ID 054
- Name
- Scott
- Primary Diagnosis
- RLE AKA, LLE BKA
- Insurance
- BCBS
- Referring Physician
- W. Cline, MD
- Age
- 56
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- White
56yo WM with RLE AKA and LLE AKA s/p MVA 38 yrs ago. Hospitalized in acute care for 6 wks with B hip fractures, severed BLEs, and internal bleeding from unknown source. Treated surgically with ORIF of B femurs, RLE AKA, LLE AKA, exploratory surgeries to locate bleed, and arterial reconstruction. D/c to inpatient rehabilitation x 1mo. Completed outpatient PT x 1yr.
Marital status:Married 25yrs
Primary language:English
Current level of function:Modified independent, completing ADL/IADLs at wheelchair-level with adaptive equipment PRN, including driving with hand controls.
Employment/work/school:College education. Works part-time as program specialist for an adaptive sports and recreation program. Work duties involve driving a work van and occasional lifting up to 20 pounds.
Play/leisure/interests:“Foodie” who loves trying new restaurants around town. Enjoys growing vegetables in his garden and travelling.
Environmental factors:Lives with wife in one-story house, 1 STE with ramp. Walk-in shower with shower curtain, flexible shower hose, tub transfer bench, no grab bars. Standard toilet, no grab bars.
Vitamin D
Calcium