History of present illness: 
84yo Asian male admitted to the hospital for C3-C7 laminectomy and fusion 2 months ago due to history of worsening spinal stenosis and spinal cord compression for at least 2 years with symptoms of paresthesia and decreasing strength. Diagnosed with incomplete quadriplegia and neurogenic bowel and bladder post-op. D/c to inpatient rehabilitation POD 3. D/c home after 3 weeks in inpatient rehab. Admitted to SNF after 1 month at home following a decline in function and a fall at home.

Past medical/surgical history:
HTN, R shoulder rotator cuff tear, R shoulder adhesive capsulitis, R shoulder tendinitis, falls (major fall 2 years ago)

Marital status: Married 62 years

Primary language: English

Prior level of function: Up until 2 months ago, client was able to perform most ADLs independently with partial assist for bathing, FWW for mobility, and partial assist from wife and daughter for household IADLs. Post-op, non-ambulatory with significant assistance for ADLs and functional transfers.

Employment/work/school: College education. Worked as a full-time pathologist with control over work tasks and environment (until 2 months ago). Work duties involve prolonged sitting at a desk working at a computer, prolonged standing and bending, and occasional lifting up to 15 pounds.

Play/leisure/interests: Enjoys giving medical lectures to colleagues and reviewing the latest medical research.

Environmental factors: Lives with wife in one-story home with 2 STE, w/c ramp installed after surgery. Tub/Shower combo with tub transfer bench and handheld shower head. BSC and several urinals for toileting. Adult daughter lives 20 minutes away and is involved in his medical care.

Cervical precautions and Miami J discontinued upon admission to SNF
Fall precautions

Gabapentin
Tylenol PRN
Lisinopril

MRI: spinal stenosis, spinal cord compression