The patient is an 86-year-old widowed woman, status post mild ischemic cerebrovascular accident (CVA) with left hemiparesis. She is receiving skilled nursing care, physical therapy (PT), occupational therapy (OT), and home health aide services through a home health agency. The patient was born in Austria and is a Holocaust survivor.
Living Environment/General Health Status:
The patient is currently living with her son and daughter-in-law in their small two-story home. The family room is used as her bedroom, which is one step down from the main level of the home (the guest bedroom is up 10 steep steps from the main level). She is using a hospital bed. The patient previously lived alone in a one-level condominium and was independent and active in the community, although she did not drive. She previously ambulated without an assistive device and enjoyed reading, crocheting, cooking, and baking. She also enjoyed playing Scrabble (a word game in which words are formed from individual lettered tiles on a game board) and participated in exercise classes through the local recreation department 2 or 3 days per week (tai chi, water walking in season, and general exercise classes). Her son, daughter-in-law, and the patient state that their collective goal is for her to return to her own home, with added services if necessary.
CVA sustained 3 weeks ago, hypertension, depression after her husband's death, urinary incontinence, and bilateral tibia/fibula fracture secondary to a motor vehicle accident approximately 15 years ago.
Sertraline, 25 mg daily; metoprolol, 50 mg daily; Aggrenox, 1 tablet twice a day; hydrochlorothiazide, 12.5 mg twice a day; valsartan, 160 mg twice a day; Acidophilus, 2 tablets three times a day; Zofran, 4 mg as needed; milk of magnesia, as needed; bisacodyl, as needed; acetaminophen, 650 mg as needed; Pepcid, 20 mg twice a day; Ambien, 5 mg at bedtime; Detrol LA, 2 mg twice a day; Colace, 100 mg twice a day.
History of Present Illness:
Patient presented to her local hospital with left-sided weakness and inability to ambulate. Initial computed tomography (CT) scan was negative. She was seen by a physical therapist and a speech and language pathologist. She was placed on nectar thick liquids secondary to dysphagia. After 5 days, she was transferred to an acute rehab hospital. She received PT, OT, and speech therapy there for approximately 2 weeks, with steady improvements in left-sided return and function. Patient experienced an episode of near syncope and was transferred back to an acute care hospital. She was diagnosed with near syncope, dehydration, and a urinary tract infection (UTI). Her UTI was treated with ciprofloxacin, 250 mg twice a day for 7 days, and her dehydration was treated with intravenous hydration. Physical therapy was resumed, and a swallowing evaluation was requested. The evaluation noted adequate improvement in swallowing to discontinue the thickened liquids. After 7 days in the acute care hospital, the patient was discharged to her ...
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