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EL – Power Mobility Device
Nov 2, 2018
•
Mark Morgan
categories:
Geriatrics & Longevity
Patient:
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Sex:
male
female
DOB:
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Age:
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Address:
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ITEM ORDERED
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Power (motorized) wheelchair
Power operated vehicle (scooter)
Date of face-to-face examination:
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Date of order:
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Start date:
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Length of need: 99 months
DIAGNOSES
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Alzheimer’s disease
Arthritis
Cerebral vascular disease
Congestive heart failure
COPD
Degenerative disc disease
Deconditioning
Degenerative joint disease
Diabetes
Diabetic neuropathy
Dialysis
Dizziness
Hemiplegia/hemiparesis
History of falls
Multiple sclerosis
Obesity
Osteoarthritis
Paraplegia/paresis
Parkinson’s disease
Renal failure
Rheumatoid arthritis
Traumatic brain injury
Wheelchair bound
USE
indoor
outdoor
quick maneuverability in tight spaces
OPTIONS
power seating system
alternate drive control interface
elevating leg rests
HISTORY
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Historian:
patient
family member/facility staff
complete history unobtainable d/t memory loss
complete history unobtainable d/t pain
complete history unobtainable d/t fatigue
Time condition(s) present:
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Setting:
living at home
resident at an assisted living facility
Maximum distance ambulated independently:
5 feet
10 feet
20 feet
50 feet
Falls:
none
occasional
frequent
risk of falls
Pressure sores:
present
none currently
history of pressure sores
AMBULATION
Cane:
not using
unable to use d/t upper extremity weakness
unable to use d/t upper extremity pain
unable to use d/t lower extremity weakness
unable to use d/t dizziness
Walker:
not using
limited use d/t fatigue
limited use d/t dizziness
uses with assistance
unable to use independently d/t upper extremity weakness
unable to use independently d/t upper extremity limited range of motion
unable to use independently d/t upper extremity pain with motion
unable to use independently d/t lower extremity weakness
Manual wheelchair:
wheeled by staff
unable to use independently d/t upper extremity weakness
unable to use independently d/t upper extremity pain with motion
Progression of ambulation difficulty over time:
improving
deteriorating
unchanged
Able to use power operated vehicle (scooter):
yes
no
requires joy stick controller
poor trunk stability
requires adjustable height armrests
unable to safely operate
requires elevating leg rests
requires fully reclining back
insufficient home space for maneuverability
ACTIVITIES OF DAILY LIVING
Reports limited activities of daily living d/t:
upper extremity weakness
upper extremity spasticity
lower extremity weakness
lower extremity spasticity
poor standing balance
poor sitting balance
poor coordination
poor endurance evidenced by shortness of breath with exertion
oxygen use
frequent falls
dizziness
ADLs requiring assistance of staff:
getting out of bed
dressing
grooming
transfer between bed, chair, & mobility device
toileting
ambulating around facility
ambulating around apartment
feeding
PHYSICAL EXAM
Weight:
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Height:
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Resting pulse:
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Exertional pulse:
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Blood pressure:
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Respirations:
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Oxygen saturation:
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Posture:
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Tremor:
no
yes
Vision:
wearing glasses
sufficient to read newspaper with glasses on
Hearing:
grossly intact to conversation
hard of hearing
Cognition:
A/O x3
able to answer questions without difficulty
Neck:
normal exam
decreased ROM
pain with motion
UE:
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normal exam
deformity
impaired strength
decreased range of motion
decreased sensation
contracture
dialysis shunt on left
dialysis shunt on right
edema on left
edema on right
LE:
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normal exam
deformity
impaired strength
decreased range of motion
decreased sensation
contracture
edema on left
edema on right
Trunk:
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normal exam
kyphosis
weakness
decreased range of motion
Sit to stand:
without difficulty
with significant difficulty
unable to perform independently
Gait:
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without difficulty
non-ambulatory
shuffling
ataxic
wide
max assist
mod assist
stops every few steps to rest
diaphoresis
tachycardia
tachypnea
Skin:
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grossly intact
wounds
NARRATIVE
This is a
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yo patient with several health problems worsening gradually over the past year despite use of multiple medications. Can no longer perform independently the majority of ADLs without significant SOB and overall discomfort. Reports doorways and halls are wide enough for a scooter that will allow access to shower, toilet, sink and dining room. Possesses physical and mental abilities to safely operate a power mobility device. Willing and motivated to use a power mobility device.
CERTIFICATION
I certify that the information provided is a true and accurate representation of my patient’s current condition and that a major reason for the visit was a mobility examination. I hereby incorporate this document into my patient's medical record.
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