• Image-1455

  • Ortega
    Client ID 034

  • Name:
    Ortega
    Age:
    70
    Primary Diagnosis:
    L CVA, acute kidney failure
    Gender Identity:
    Male
    Insurance: 
    Medicare
    Pronouns:
    He/him/his
    Referring Physician: 
    Hansel Jackson, MD
    Race/Ethnicity:
    Hispanic/Latino

  • History of present illness: 
    70yo Hispanic M admitted to the hospital 3 months ago with R-sided weakness and numbness. Diagnosed with L CVA, dysarthria, and vascular dementia. Developed acute kidney failure while in hospital. After 3 weeks in acute care, d/c to skilled nursing facility. Transitioned to the long-term care unit after 4 weeks.

    Past medical/surgical history:
    Gout, HTN

  • Marital status: Widowed 2 years ago.

    Primary language: Spanish. Also fluent in English.

    Prior level of function: Prior to hospitalization, independent with ADLs. Ambulated with FWW. Required partial assistance with IADLs.

    Employment/work/school: High school education. Retired plant production worker.

    Play/leisure/interests: Enjoys gardening and woodworking.

    Environmental factors: Lives alone in one-story condo in assisted living facility with no STE. Zero-entry shower with built-in shower chair, handheld shower head, grab bars, and raised toilet seat.  6 adult children, 5 of which live locally. Eldest son’s family (including 3 grandchildren) visits weekly.

  • OOB
    WBAT

  • (coming soon)

  • MRI: L CVA
    CT scan: acute kidney failure

  • Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.

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