Medical Intake / History Review - 2160 Words

Life Care Plan for Mr. Robert Vince Date of Report: December 12, 2014 Source of referral: Department of Veterans Affairs Client: Mr. Robert Vince Date of Birth 11/17/1957 Age: 57 Social security number: 123-45-6789 Date of Injury: May 15, 2014 Medical Intake/History Review Mr. Vince is a 57 year old African American male referred by the Department of Veterans Affairs. The referral is in reference to the development of a Life Care Plan and required home modifications that addresses the patient’s lifetime disability medical needs secondary to a motorcycle accident that resulted in paraplegia due to T7 thoracic injury. Mr. Vince has prior military experience, but was not service connected to any†¦show more content†¦Unfortunately, the room is too small for a clinitron bed to fit in it and other medical equipment needed to care for the patient. There is only a half bath downstairs; therefore, the spouse has to use a basin to give her husband a bed bath. Her desire is for her husband (patient) to be able to maneuver in the house utilizing his wheelchair. Chief Complaint and Subjective History by Patient Patient incurred a T7 thoracic injury and has no lower extremity functional ability. At present the patient has a stage two sacral decubitus, urinary tract infection, and muscle spasms in his lower extremities. The sacral ulcer was caused from the lack of frequent position changes while in bed and improper seating in the wheelchair. The wound requires daily dressing changes and more frequent if soiled from urinary and fecal contamination. The urinary tract occurred from the patient intermittently cauterizing himself with a straight catheter every four hours. The patient has also been experiencing spontaneous uncontrolled spasticity in the lower extremities. Mr. Vince states he was 56 years old on the date of his motorcycle accident; he lost control of the motorcycle when a vehicle cut in front of him. The patient was pinned between his motorcycle and the guard rail on the highway. When EMS arrived, the patient was reported to need