Client Note (Sylvia)
Sylvia
Client ID 060
- Name
- Sylvia
- Primary Diagnosis
- Multiple Sclerosis
- Insurance
- BCBS
- Referring Physician
- F. Lowell, MD
- Age
- 45
- Gender Identity
- Female
- Pronouns
- She/her/hers
- Race/Ethnicity
- Hispanic
45yo Hispanic female diagnosed with multiple sclerosis 18 years ago. MRI revealed lesions indicative of multiple sclerosis. Hospitalized x1 wk in acute care for baclofen pump complications and catheter revision. D/c to inpatient rehabilitation for 10 days. Received outpatient PT services for 3 months and continues to intermittently receive outpatient PT as needed.
Marital status:Single
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. Retired background investigator.
Play/leisure/interests:Enjoys participating in adaptive sports program activities, including hand-cycling, bowling, and rowing. Makes jewelry, practices silversmithing. Also enjoys attending bible studies and traveling.
Environmental factors:Lives with brother in single story house, 1 STE, with ramp. Roll-in, zero-entry shower with rolling shower chair, handheld shower hose, and shower curtain. Standard height toilet with grab bars.
Baclofen
Gabapentin
Ocrelizumab