Client Note (Steven)
Steven
Client ID 051
- Name
- Steven
- Primary Diagnosis
- Quadruple amputation
- Insurance
- Cigna
- Referring Physician
- B. Nance, MD
- Age
- 35
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- White
35yo WM with quadruple amputation 12 years ago (BLE BKA, BUE BEA) to prevent spread of rare bacterial infection. Comatose for 3 months in acute care with tracheostomy. D/c to inpatient rehabilitation for 1 month, followed by 1 year of outpatient physical and occupational therapy.
Marital status:Dating girlfriend for 3 years
Primary language:English
Current level of function:Modified independent, completing ADL/IADLs at wheelchair-level or with BLE prosthesis, adaptive equipment PRN. Use of paratransit.
Employment/work/school:College education. Part-time human resources assistant. Work duties involve prolonged sitting at a desk and rarely lifting up to 15 pounds.
Play/leisure/interests:Enjoys participating in adaptive sports program activities, including wheelchair rugby and billiards. Plays video games online with friends from college weekly. Enjoys watching television with girlfriend in the evenings.
Environmental factors:Lives with girlfriend in apartment on first floor with 1 STE, no handrails. Tub/shower combo with tub transfer bench and handheld shower hose, no grab bars.
Gabapentin
Setraline
NSAIDs