Client Note (Jo)
Jo
(Client ID 024)
| Name: Jo | Age: 75 | Admit date: 3 days ago | MR #: 000-024 |
| Gender Identity: Female | Race: Caucasian |
Admitting diagnosis: Dementia |
Insurance: Medicare A |
| History of present illness: Jo is a 75-year-old female with a diagnosis of dementia s/p hospitalization for a UTI with sepsis and severely altered mental status. After hospitalization she was having difficulty with weakness and mobility and was transferred to rehab in the SNF. Upon entering the facility, she was evaluated for PT, OT, and SLP. | |
| Past medical/surgical history: HTN, frequent UTIs |
| Social History: Jo is a widowed mother of 4 living in an assisted living facility. Her 4 adult children are all involved in her care; however, her eldest daughter and youngest son live in the same town and alternate visiting her daily. | |
| Employment/work/school: Retired school teacher | |
| Prior level of function: Jo has a full-time aide that comes in every morning to help with bathing and dressing and stays with her until one of her children arrives to assist with nightly routine. The facility provides 3 meals daily. | |
| Living situation/ Environmental barriers: Jo lives in a continuing care retirement community. She currently resides in assisted living; however, her children and the staff have determined that she requires more care than the assisted living is able to provide. She was placed on the wait list for the facility’s memory care unit. Until she is able to transition to the floor, the family hired a full-time aide during the day, and one of her children comes each night. |
Memantine
Amlodipine
Nitrofurantoin
Miralax
Tylenol
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.