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Patient Note (Marsha)

Marsha

(Patient ID 021)

Find patient record:
Name: Marsha Age: 67 Admit date: N/A MR #: 000-021
Gender Identity: Female Race: White Admitting diagnosis:
Multiple Sclerosis 		Insurance: Medicare
History of present illness: Marsha is a 67 yo WF with recent MS exacerbation. Home Health occupational therapy was consulted for evaluation, treatment, and home safety evaluation.
Past medical/surgical history:
Carpal tunnel in R wrist
Asthma
Social History: Marsha is a widow and lives alone with family that checks in with her regularly.
Employment/work/school: Marsha is retired and has an undergraduate art degree in printmaking and bookbinding.
Prior level of function: Prior to her current exacerbation, Marsha was independent with activity and home modifications. She is now having increased fatigue and weakness making cleaning tasks and hobbies difficult to complete.
Patient concerns: Marsha reports fearing that she will fall in her home and be unable to reach a phone to notify family. She reports having increased difficulty with everyday activities, in particular cleaning tasks. In addition, she worries that weakness and fatigue will interfere with her ability to continue with her hobbies.

Albuterol PRN

Flovent inhaler daily

Rituximab

Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.