• Image-1455
  • Andy
    Client ID 049

  • Name:
    Andy
    Age:
    70
    Primary Diagnosis:
    Progressive supranuclear palsy
    Gender Identity:
    Male
    Insurance: 
    Medicare
    Pronouns:
    He/him/his
    Referring Physician: 
    J. Wu, MD
    Race/Ethnicity:
    White
  • History of present illness:
    70yo WM with progressive supranuclear palsy, initially diagnosed 5 years ago after developing recurrent posterior losses of balance and reduced volume of speech. Currently receives outpatient OT, PT, and SLP services.

    Past medical/surgical history:
    Type 2 diabetes, diabetic coma, kidney disease, dry eye disease, dry mouth, glaucoma secondary to diabetes, Charcot foot with foot reconstruction surgery

  • Marital status: Married 49 years.

    Primary language: English.

    Current level of function: Requires partial assist for ADLs. Ambulates with rollator. Requires substantial assist for IADLs. Does not drive. Wife reports client can be overconfident at times and requires supervision for safety.

    Employment/work/school: College education (law degree). Managed family dairy farm until elected youngest member of state legislature. Worked as a radio talk show host after public service, but is now retired.

    Play/leisure/interests: Enjoys participating in adaptive sports program activities, including orchestra (clarinet and percussion), bowling, fishing, golfing, and archery. Still keeps up-to-date on politics through watching and reading the news every morning. Continues to be involved in advocacy, especially related to agricultural policies, but reports typing has become difficult.

    Environmental factors: Lives with wife in a two-story house. 3 STE with custom ramp, no handrails. Bedroom, bathroom, living room, dining area, and kitchen on first floor. Zero-entry shower with shower chair, handheld shower head, grab bars, and bedside commode over toilet. Mainly uses rollator but also owns a FWW and U-Step walker. Occasionally uses a standard wheelchair in the community. His adult son lives locally and provides assistance intermittently.

  • None

  • Levadopa
    Lyumjev
    Lantus
    Tovistatin
    Pilocarpine
    Supplements (Vitamin D, B12, Zinc, Probiotics, Berberine, Magnesium)

  • MRI: Marked atrophy in midbrain ("hummingbird sign") and mild cortical thinning in frontal lobe, highly suggestive of Progressive Supranuclear Palsy

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

  • Should be Empty: