Rehab Potential: A Case Study

Decent Essays
Rehab Potential: good

Clinical Summary
This is a 58 yo female who was hospitalized for brain mass, associated with headaches. The masses was surgical removed. Pt also has two Lung nodules right upper lobe. Pt a white patch in her mouth which looks like thrush. I spent a long time calling around to find some see the pt. Pt does not have stabilized PCP. I called the inpatient doctor and talk to the doctor assistance. The doctor is not in service and since she is discharged from hospital, finding a doctor to treat her thrush was not successful. I told the patient to go to mini-clinic or urgent care. Pt was discharged with a liquid oxycodone and a voucher for oxycodone table. I called to Brianna, Case manager at GMC, and fixed the problem. Pt’s
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Post-op care, SN to assess incision for s/s of infx or complications, medication teaching, and pain management teaching.
Has the patient been in an inpatient facility in the past 30 days? Yes,
If yes, reason for admission: brain mass.
Were there any complications? no
If yes, summarize complications:

Has a specific body site been affected and/or has the disease process/surgery affected patient's dominant side? no neurologic deficits

Pertinent past medical/surgical history: migraine headaches, Smoking, and tuba ligation.
Prior level of functioning: (ambulation/transfer ability (include reasons for other disciplines seeing patient)) Pt has decreased gait skills and dynamic balance, increased pain, increased anxiety/agitation, and healing incision. PT will work with pt.

If patient has refused other ordered services, why? No

New Medications started? yes
If yes, please list and describe medication teaching completed. Pt’s c/g is independent with her medication management.

If patient has ulcer, wound, or incision--describe type, stage, location and healing status wound
Appearance: appears to be healing well with good re
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