Patient Note (Dr. T)
Dr. T
(Patient ID 028)
| Name: Dr. T | Age: 84 | Admit date: 3 months ago | MR #: 000-028 |
| Gender Identity: Male | Race: Asian |
Admitting diagnosis: C3-C7 laminectomy and fusion |
Insurance: Medicare A |
| History of present illness: History of worsening spinal stenosis and spinal cord compression for at least 2 years, with symptoms of paresthesia and decreasing strength. Patient declined surgery and continued to work until condition had significant impact on function. Patient underwent C3-C7 laminectomy and fusion followed by in-patient rehabilitation (3 weeks) and was discharged to home. He was subsequently diagnosed with neurogenic bowel and bladder. He was admitted to SNF rehab unit following a decline in function and fall at home. | |
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Past medical/surgical history: HTN R shoulder rotator cuff tear R adhesive capsulitis R shoulder tendinitis Falls – major fall 2 years ago |
| Social History: Dr. T lives with his wife. He has spent his life dedicated to his medical practice and worked full time until condition worsened. He enjoys giving medical lectures to colleagues. His adult daughter lives 20 minutes away and is involved in his medical care. | |
| Employment/work/school: Full time employment as a pathologist. | |
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Prior level of function: Before worsening spinal cord compression, he was working as a pathologist with control over work tasks and environment. He used a folding front wheeled walker for mobility. Performed most ADLs independently, with assist for bathing. After surgery Dr. T was quadriplegic with neurogenic bowel and bladder. He became non-ambulatory and needed significant assistance with transfers and ADLs. Experienced a fall at home leading to admission into rehab facility. |
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| Living situation/Environmental barriers: Lives in a single-story home with two steps to enter. Wheel chair ramp was installed after surgery. Patient owns a bedside commode and several urinals. Bathroom contains a tub/shower combo with a tub transfer bench. |
Cervical precautions and Miami J use discontinued upon admission to SNF/rehab by M.D. (6 weeks post-op)
Fall Precautions
Gabapentin
Tylenol PRN
Lisinopril
HR- 80
RR- 26
BP- 130/85
Temp: 98.6F
O2: 99% on room air
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.