The patient is an 84-year-old man with a 9-year history of Parkinson's disease*.
History of Present Illness:
The patient has experienced a recent deterioration of balance, gait, endurance, and strength. He was hospitalized for 12 days to monitor the deterioration and adjust medications accordingly. The patient was then transferred to an inpatient rehabilitation facility for 2 weeks, has received home physical therapy for 4 weeks, and now has been referred for outpatient physical therapy.
Patient reports prostate cancer, left upper extremity (UE) adhesive capsulitis (status post trauma from a motor vehicle accident), and depression.
Patient reports right total knee arthroplasty (status post 8 years), left total knee arthroplasty (status post 4 years), and left total hip arthroplasty (status post 3 years).
Sinemet, Mirapex, Lexapro, iron, and Zocor.
The patient is retired and lives with his wife. She is also retired and able to provide limited assistance during the day secondary to her history of cardiac disease. A recently hired aide provides 4 hours of assistance per day.
The patient lives in an apartment with no steps. He has the following durable medical equipment: straight cane, tripod rollator, shower chair, commode, and two grab bars installed in the bathroom.
General Health Status:
Prior Level of Function:
Prior to last hospitalization, the patient ambulated independently with a straight cane.
Current Level of Function:
The patient ambulates using a straight cane at home for short distances and ambulates outside with a rollator and contact guard assistance secondary to imbalance and fall risk. The patient reports an average of three falls per month. He uses a motorized scooter when traveling farther than four blocks. He reports difficulty with rolling in bed in both directions, transferring from supine-to-sit and sit-to-stand, donning and doffing clothes, and eating.
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