• Image-1455

  • Corey
    Client ID 045

  • Name:
    Corey
    Age:
    39
    Primary Diagnosis:
    SCI
    Gender Identity:
    Male
    Insurance: 
    Medicaid
    Pronouns:
    He/him/his
    Referring Physician: 
    N. Kent, MD
    Race/Ethnicity:
    White

  • History of present illness:
    39yo WM with ASIA D SCI (C7, motor incomplete) sustained 7 yrs ago from MVA. Hospitalized for 1 month in acute care. D/c to inpatient rehabilitation where he stayed for 4 mos. Received outpatient OT/PT for 15 mos.

    Past medical/surgical history:
    Spinal decompression, spinal fusion

  • Marital status: Single.

    Primary language: English.

    Current level of function: Modified independent for ADL/IADLs with adaptive equipment PRN, including driving with hand controls. Ambulates with NBQC.

    Employment/work/school: High school education. Currently unemployed.

    Play/leisure/interests: Enjoys participating in adaptive sports program activities, including billiards, pickleball, and wheelchair rugby. Follows college football and basketball, meeting with friends regularly to watch the games.

    Environmental factors: Lives alone in a first floor apartment with 1 STE, no handrails. Tub/shower combo with shower curtain, handheld shower head, tub transfer bench, nonskid mat, grab bars. Raised toilet seat with grab bars. Uses built-up utensils. Has one brother who lives across the country and cannot help routinely.

  • Fall precautions
    May ambulate if BP is above 110/70

  • Gabapentin
    Baclofen

  • X-ray: L femoral neck non-displaced fracture

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

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