Client Note (Test)
Alice
Client ID 008
- Name
- Alice
- Primary Diagnosis
- L CVA
- Age
- 63
- Gender Identity
- Female
- Insurance
- Medicare
- Pronouns
- She/her/hers
- Referring Physician
- K. Garrison, MD
- Race/Ethnicity
- White
History of present illness:
63yo WF with h/o L CVA diagnosed 10 years ago. Currently returning to outpatient therapy to improve RUE tone and functional use.
Past medical/surgical history:
HTN, endometriosis, hysterectomy
Diagnosed with L CVA ten years ago after being noted with increasing fatigue and inability to speak. Her recovery included 3 weeks in acute care, 6 weeks in inpatient rehabilitation, and three months in outpatient therapy.
Social History
Marital status: Married 41 years
Primary language: English
Prior level of function: Prior to stroke, independent in ADL/IADLs, including driving. Currently independent in ambulation without use of assistive device. Modified independent with ADLs with assistive devices PRN and increased time. Partial assist for IADLs.
Employment/work/school: College education. Retired financial analyst for IBM.
Play/leisure/interests: Enjoys taking care of raised herb garden and reading.
Environmental factors: Lives with husband and pet yorkie in one-story house with 2 STE, no handrails. Walk in shower (2” ledge) with shower curtain, shower chair, handheld shower head, wash mitt, and grab bars. Raised toilet seat with grab bars. Two adult children - one lives locally and visits weekly, other lives 3 hours away and visits bimonthly.
MD Orders
R AFO
Medications
Coumadin
Lasix
Test Results
MRI: L CVA