Interpersonal Communication Case Summary

DOI: 7/28/2016. Patient is a 44-year-old female communication strategist who sustained injury while she was walking to a meeting when she tripped and fell. Per OMNI, she was diagnosed with severe spinal cord compression at C4-7 with myelopathy and L4-5 and L5-S1 degenerative changes. Patient is status post cervical laminectomy from C3 through C7 with posterior cervical fusion on 09/06/16.
Per the medical report dated 09/09/16, the patient was diagnosed with severe cervical myelopathy and stenosis and underwent surgery on 09/06/16. Post-operatively, she was placed on Aspen collar. She was stabilized. Because of her myelopathy, physicians recommended that she come to the rehabilitation hospital to see if her functional status can be increased.
Her muscle testing for the left upper extremity is 5-/5. Right upper extremity strength is 4/5. She requires moderate to maximum assistance with activities of daily living and transfers. Impression includes mobility and self-care deficits secondary a fall with progressive cervical myelopathy, status post 09/06/16 posterior decompression and fusion at C3-7; neurogenic pain; and increased risk of deep vein thrombosis. It was noted that because of her mobility and self-care deficits, she requires 24-hour rehabilitation nursing care. MD will obtain bilateral venous surveillance Dopplers of the lower extremities. Patient will be instructed on how to do heel pumps. She will be seen by PT, occupational therapy, rehabilitation nursing, case management and physiatry. She will undergo interdisciplinary rehabilitation receiving therapy at least 3 hours a day, 5 days a week. Ultimate goal is to obtain a level of modified independence in all activities of daily living, transfers, ambulation, and assistive device to increase her strength and endurance and get back home safely with the husband. Estimated length of stay is 18-21 days. She will continue on Norco and Percocet. Lyrica will be added for neurogenic