Life Care Plan

PREPARED BY: xxxx, RN, CCM, CPUR, LCP

Life Care Plan Completed:

TELEPHONE PRE-EVALUATION: 05/02/12

DATE OF EVALUATION: 05/18/12

DATE REPORT INITIATED: 06/02/12

REPORT FINALIZED: 06/11/1

SUMMARY/INTRODUCTION:

Stan XXXXX is a 69-year-old Caucasian male seen for evaluation in his residence accompanied by his wife, Suzie, on 5/18/12.  Prior to this on-site evaluation, a telephone pre-evaluation was accomplished by xxxx, on 5/2/12 for the purposes of identifying specific demographic information, establishing a list of treating professionals, equipment, supplies and past work history.

His attorney, XXXX, referred Stan for a rehabilitation evaluation.  The purpose of this evaluation is to assess the extent to which handicapping conditions impede his ability to live independently and handle all activities of daily living.

DEMOGRAPHIC INFORMATION:

Client Name:  xxxx; Social Security #:  XXXX; Address:  XXX; County:  XX; Closest Metro Area:  XXX (45 minutes distance maximum); Phone:  XXX Birthdate:  4/1/43; Age:  69; Sex:  Male; Race:  Caucasian; Marital Status:  Married; Birthplace:  XXX Citizen:  Yes; Elementary/Secondary Education:  Elementary and High School in XXX (See college under Education Section); Employer at time of injury:  Retired; Position/Grade:  XXX; Bilingual:  No; Glasses:  Reading; Dominant Hand:  Right; Height:  5’ 9”; Weight (present):  200-210 lbs.; Weight (pre-injury):  240 lbs.; Date of Onset:  5/1/06

DIAGNOSIS / DISABILITY:

• Open book pelvic fracture (diaphysis symphysis pubis, diaphysis bilateral sacroiliac joint and left inferior pubic ramus fracture)
• Fracture of the left ribs with left pneumothorax
• Respiratory failure, 5/4/06
• Deep venous thrombosis, bilateral LE’s
• Paroxysmal atrial fibrillation (new onset), converted
• Syndrome of inappropriate antidiuretic hormone secretion
• Hyponatremia-corrected
• Hypokalemia-corrected
• Prerenal azotemia-corrected
• Inferior vena cava filter, 5/3/06
• Alcohol withdrawal
• Hypertension
• Lipid disorder
• Morbid obesity
• S/P Stananoma excision
• Anemia (acute blood loss type).

Loss of Consciousness or Altered State of Consciousness:  No.

Length of Unconsciousness or of Altered State:  N/A.

Independent Recall:  Full recall, although he was in a state of shock.
CURRENT DISABILITY:

Disabling Problems:  (By client/family history and report.  No physical examination occurred)

xxxx: “They told me my pelvis was broken and split open four inches.  I had to wait until my body was stabilized at City 2 Hospital before I could be transferred to City General for surgery because they had better expertise.  There were several delays because of complications.  After that surgery, the hope was the nerves would not be too damaged to prevent my walking again but that was expressed as a possibility.  They also pinned my hip through my spine.  I also had broken ribs.  Therapy was begun but I felt significant pain sufficient to almost cause me to pass out and that is when they found out this was emanating from the vertebrae and that is when they told me I needed surgery on T6 due to a Thoracic Burst fracture.

I have hardware from T6 through T9.  I re-entered PT with some success but getting up in their standing frame was still limited to a minute at the most before I had to sit back down.  During this effort, the therapist failed to secure the chair and I fell down.  They had to re-x-ray everything.  They did have to surgically drain an infection from the pelvic surgery.  

I also had an episode of pneumonia from prolonged bed rest.  I am not able to walk independently at all. With a walker I use my arms and shoulders to provide primary support.  With the walker, gritting my teeth and really trying I can probably go at least twenty feet with therapy assistance X’s two for safety and wearing a PT belt.”  (This is once per therapy session and he is far from either home or community ambulation.)

He is continent of bowel and bladder.  Once each morning he tries to empty his bowel.  Over the last ten days, he has had success at emptying his bowel and bladder and this helps him set the tone for the day.  In the last three months prior to this, he had bowel incontinence daily requiring help from one of the aides or Suzie to clean him up.  If he fails to urinate or have a bowel movement he has no idea when he may have a movement the next time.  Suzie sleeps in the Master Bedroom just the next room over.  She listens carefully for him and attends immediately if he requires help.  He is now on Flomax and seems to have his bladder and urination under control.  His hemoglobin has been low and there has been no determination, as yet, as to why.  He will keep me informed as to how his efforts at bowel management are going and if in two weeks he is still not successful he will call and we can discuss the next step in bowel management.

Spouse:  “He has lost the ability to walk; he needs help to stand, he cannot sit up without a plastic back/front brace, he is fatigued, he is in pain all the time (pain is at a lower level than it was earlier).  He needs assistance moving side-to-side in the bed just for comfort.  He is involuntarily incontinent with bowel and needs to be changed.  He is 80% continent of bladder.  He usually will have a bowel movement when he urinates, but he is unable to tell he is about to have a bowel movement.  There is no sexual function.”

“In his fatigue, his thinking is slow and he has moments when he is fine, but he depends on me for a lot of decisions, which is totally different from before.  He was a quick thinker before and now not so much.”  

He anticipates continued wearing of the clam-shell brace through August and then it will be assessed to see if he needs it further.  It was recommended he wear the brace for one year.

Pain – Knees down including feet:  Never pain-free, but the pain does vary in intensity.  The following ratings are while he is on medication.  The lowest level of pain he will experience in a 24 hour period is rated at a 2 “if I do not move them at all”.   The average pain he is experiencing the majority of the day is a 2-3.  The worst pain he experiences is 8.  “This generally occurs the first time I try to stand in a day or whenever I accidentally bump it.  I have been told I have a fairly high pain tolerance.  The pain is unique almost like how you feel when you have pins and needles and you bump your limb on something.  There is nothing I can do to relieve the increased pain when it gets worse but just wait it out.  The elastic support hose helps a little bit.  I do get swelling in the lower legs.”  

Pain – Low and mid back:  Never pain-free, but the pain does vary in intensity.  The lowest level of pain he will experience, while on medication, in a 24 hour period is rated at a 1, “If I am lying in bed and not moving at all.”  The average pain he is experiencing the majority of the day is a 3+.  The worst pain he experiences is 8.  This generally occurs due to movement or prolonged sitting with no movement.  “To relieve the pain I try to stretch the back by bending forward or I have to lie back down.”  

MEDICAL SUMMARY / MEDICAL RECORD REVIEW:

Patient:

D.O.B.:  4/1/43

D.O.I.:  5/1/10

Date of Medical Summary:  4/26/12

xxxx is a 69-year old Caucasian male who sustained a spinal cord injury at level T6 (lumbar-sacral plexopathy with paraparesis) as a result of a fall down an elevator shaft.  

COUNTY EMS:  5/1/10

Responded to call at xxxx.  History indicated xxxx stepped into an empty shaft falling approximately 12 – 15 feet.  He denied loss of consciousness.  He did get up and walk a few feet out of the shaft and lay down on a concrete floor.  Upon arrival, he complained of back and hip pain.  He had a laceration to the back of his head.  He had positive back pain, thoracic to lumbar.  There were abrasions across the entire top of his back from about C7 to mid scapula.  There was bruising to lumbar area.  He had severe left hip and lumbar pain. xxxx was turned over to XXX for air transport to hospital.

MEMORIAL HEALTH SYSTEM:  5/1/10 – 5/15/10

Arrived via air transport.  History indicated no loss of consciousness; Glasgow Coma Scale was 15 on arrival. CT of the abdomen and pelvis revealed an open book pelvic fracture that manifested as diaphysis of his symphysis pubis in both sacroiliac joints with a fracture to the left superior pelvis.  Urethrogram was normal.

CT of the chest and chest X-ray both confirmed left rib fractures and a small left pneumothorax without any pulmonary compromise.  Cervical, dorsolumbar spine and left femur films were all negative for fracture.

xxxx had chest X-rays, which showed no pulmonary complications.  Orthopedic consultation was obtained and transfer to a tertiary center for pelvic fracture surgical stabilization was recommended.  However, on 5/4/06, Stan developed acute respiratory distress and went into respiratory failure requiring intubation.  He was subsequently found to have deep venous thrombosis (DVT) of both LE’s.  CTA of the chest, however, did not show typical evidence for pulmonary embolism, acknowledging there was good movement and the study was of poor quality.  While on telemetry, he then developed a paroxysmal atrial fibrillation.  He was seen in cardiac consultation and was chemically converted.

xxxx then developed features of SIADH (syndrome of inappropriate anti -diuretic hormone secretion) with hypokalemia, hyponatremia and prerenal azotemia.  He was given multivitamins and this resolved.  His only other medical problem was acute blood loss anemia without coagulopathy.  

At time of discharge, xxxx had normal sinus rhythm.  His hyponatremia and hypokalemia were improving. He was going through DT’s (delirium tremens) without complications.  Anticoagulation had been held per cardiology request in view of his multi-trauma and therefore he had placement of an IVC (inferior vena cava) filter on 5/3/10.  There was no evidence of pulmonary embolism.  

Arrangements were made for transfer to xxxx General Hospital for surgical treatment of pelvic fracture. Alcohol abstinence was encouraged at discharge.  Discharge diagnoses:

• Open book pelvic fracture (diaphysis symphysis pubis, diaphysis bilateral sacroiliac joint and left inferior pubic ramus fracture)
• Fracture of the left ribs with left pneumothorax
• Respiratory failure, 5/4/10
• Deep venous thrombosis, bilateral LE’s
• Paroxysmal atrial fibrillation (new onset), converted
• Syndrome of inappropriate anti-diuretic hormone secretion
• Hyponatremia-corrected
• Hypokalemia-corrected
• Prerenal azotemia-corrected
• Inferior vena cava filter, 5/3/10
• Alcohol withdrawal
• Hypertension
• Lipid disorder
• Morbid obesity
• S/P Stananoma excision
• Anemia (acute blood loss type)

CITY GENERAL HOSPITAL:  5/15/10 – 10/14/10

Transferred from xxxx Hospital for definitive repair of his orthopedic problems (Dr. xxxx).  He underwent ORIF (open reduction-internal fixation) of a pelvic fracture.  He had APC II pelvic fracture with left sacroiliac widening and a left anterior column acetabular fracture.  He developed what appeared to be a wound infection and was later taken back to the OR for incision and drainage of a complex postoperative wound infection.

Hospital course was complicated by Heparin-induced thrombocytopenia (HIT), deep venous thrombosis (DVT) and IVC (inferior vena cava) filter.  He had coagulopathy, left pleural effusion and anemia.  He had atrial fibrillation with rapid ventricular response.  Multiple consultations were obtained.  He eventually stabilized and subsequently transferred to the rehabilitation center.  In rehab, he had persistent flank area pain.  He was found to have a T6 compression fracture.  Subsequently, he was transferred back to the acute care center and underwent T3-T9 fusion with instrumentation.  He again stabilized and was transferred again to rehabilitation on 9/2/06 for the continuation of the rehabilitation program.  Hospital course by specialty was as follows:

Gastrointestinal:  Stan had GI bleed with coffee ground emesis.  Colonoscopy was grossly normal. Esophagogastroduodenoscopy revealed a gastric ulcer as well as evidence of duodenitis and gastritis.  He also had evidence of gastric reflux and esophagus was dilated.  Ultrasound of the liver revealed fatty liver disease. He was maintained on proton pump inhibitor.  He did not have recurrent bd.  Follow up post-discharge would be needed for gastric ulcer and to determine if esophageal stricture resolved.  He was to continue on Protonix and follow up with gastroenterology.

Urology:  xxxx was followed and treated for hematuria.  Urine cytology was abnormal with atypical cells.  CT of the abdomen revealed a non-obstructive stone but no evidence of infection or obstruction.  Renal ultrasound was negative.  Cystoscopy revealed mild cystitis but no abnormality.  Hematuria subsequently resolved without difficulty.  Stan was advised to follow up with urology on an outpatient basis for evaluation and management long-term.  Urine was clear and he was continent of bowel and bladder.  

Cardiovascular:  During his acute stay, xxxx had an episode of atrial fibrillation with rapid ventricular response.  He returned to sinus rhythm with medical treatment.  He was also treated with Coumadin.  On admission to acute care, his ejection fraction was 60%.  He had followed up echocardiogram in rehab which revealed ejection fraction of 45% with mild left atrial enlargement.  There was slight anterior and septal hypokinesia.  Hemodynamically, he remained quite stable.  He had no evidence of congestive heart failure.  His exercise tolerance was good.  He had good sinus rhythm by clinical evaluation and palpation throughout his stay at the rehab center.  It was recommended, however, that he follows up with his primary care doctor and would benefit from a repeat echocardiogram just to be sure his ejection fraction had not worsened and for further evaluation his hemodynamics.  

Hematology:  xxxx had DVT in the bilateral LE’s diagnosed early during his initial stay at the acute care facility.  He again had ultrasounds done in the LE’s on his second visit to acute care, which still established that he had LE deep venous thrombosis.  In rehab, on his second admission, fever workup revealed UE DVT.  Furthermore, he had a history of Heparin-induced thrombocytopenia in acute care.  He had 1-2+ LE edema, which was multifactorial but mostly due to paraparesis and DVT.  The swelling improved over time.  He was to continue on Coumadin.  Follow up with primary care physician was recommended to monitor Coumadin level.  

Pulmonary:  From a pulmonary standpoint, xxxx was seen due to persistent pulmonary infiltrate and abnormal chest X-ray.  Repeat chest X-rays revealed no effusions, no pneumothorax, and borderline cardiomegaly.  There was no further evidence of pulmonary infiltrates.  Stan was completely stable from the pulmonary standpoint at time of discharge.  

Infectious Disease:  While at rehab, xxxx developed a fever; panculture grew out MSSA in his blood with colonization.  Dr. xxxx recommended 6 weeks of IV antibiotic management.  He was started on Oxacillin but developed a rash and was switched to Cubicin.  Follow up with the infectious disease was recommended post discharge.

Spine:  xxxx was followed by Dr. xxxx of spine surgery.  He was noted to have a C6 burst fracture with evidence of T6 stenosis.  Because of the fracture, a surgical intervention was recommended and Stan underwent a T5 hemilaminectomy with a T3-T9 fusion with instrumentation and grafting.  He was wearing a TLSO brace with cervical extension.  He had minimal pain complaints in regards to his back.  Follow up with pain management or primary care physician was recommended post discharge.

Orthopedic:  Followed by Dr. xxxx.  He had a pelvic fracture and had ORIF complicated by an infection that required irrigation and debridement.  The orthopedic assessment revealed an APC II pelvic fracture with left S1 widening and left anterior column acetabular fracture.  In addition, he had evidence of paraparesis. EMG/nerve conduction study confirmed a bilateral lumbar-sacral plexopathy.  Most of the impairment was motor with weakness but sensory was intact and bowel and bladder were intact.  Reflexes were essentially zero at the knee and ankle.  His tone was low.  He had full ROM, but tended to be in a frog-leg position consistent with a pelvic fracture.  He needed to be ranged daily to prevent contracture.  His weakness was noted to be mostly flexion as compared to an extension.  His weakest musculature tended to be the hip adductors and the ankle dorsiflexors.  His strength ranged from approximately 2-/5 to 3+/5.  He was weight bearing as tolerated.  The biggest concern was contracture development, especially at the hips and ankles.  It was recommended he continue aggressive ROM program following discharge.

Rehabilitation:  xxxx was very cooperative and motivated.  He participated fully in rehab.  He was continent of bowel and bladder.  OT reported that grooming and feeding were independent, upper body dressing was minimal assist and lower body dressing was moderate assist.  His endurance was limited.  PT reported Stan was able to get in and out of bed with minimal assist.  He transferred via a lateral scoot with minimal assist.  He was nonambulatory.  He propelled his wheelchair 150 feet with supervision.  Outpatient PT was recommended.

xxxx was discharged home with a very supportive wife who had undergone all family education.  She made adaptations to the house.  Discharge equipment included a hospital bed, wheelchair with cushion, bedside commode, and shower chair.  They planned on hiring an assistant to help with care at home.  Home health nursing, PT, OT and aide services were arranged.  Discharge activity was out-of-bed 2-3 times/day.  xxxx was advised to wear a brace at all times when out of bed.  Discharge diagnoses:

• Pelvic fracture S/P ORIF
• Lumbar-sacral plexopathy with paraparesis
• Pelvic wound infections S/P irrigation and debridement
• T6 burst fracture S/P ORIF
• Upper GI bd
• Esophageal dilation
• Hematuria
• Heparin-induced thrombocytopenia
• Bilateral LE deep venous thrombosis
• Bilateral UE deep venous thrombosis
• IVC (inferior vena cava) filter placement
• MSSA bacteremia
• Anemia
• Chronic pain
• Debility

SPEC, XXXX M.D.:  10/18/10

Internal medicine follow-up.  xxxx was recently discharged from City General Hospital where he was inpatient for about 5 months.

xxxx was on 6 weeks course of Cubicin via Home Nursing Inc.  Nursing for MSSA blood culture while hospitalized.  He was on significant pain management since his T6 surgery.  He had documented LE lumbar spine plexopathy with LE weakness.  At the time of dictation, he was unable to walk or accomplish transfers without assistance.  He was in surprisingly good spirits in spite of his problems and was doing all that he could to stay upright in a wheelchair and be as active as possible since arriving home four days earlier.  A long time was spent discussing household management with his family as it was clear Stan was going to need a lot of nursing care.  The wife reported he was sleeping well through the night.

Follow up was left open as xxxx was unable to easily come to examiner’s office.  House calls were discussed. Examiner strongly urged wife to interview outside help.  Examiner’s nurse would interface with Home Nursing Inc. in order to ensure that PT was an ongoing process.  Prescription for Duragesic patch issued.

REHABILITATION PROGRAM:

xxxx was initially in xxxx Hospital from 5/1/06 through 5/15/06. He was then transferred to xxxx Hospital where he was admitted on 5/15/10.  

xxxx Hospital 5/15/10 – 10/14/10 – Acute Stay and Rehab.: He participated fully in rehab.  He was continent of bowel and bladder.  OT reported that grooming and feeding were independent, upper body dressing was minimal assist and lower body dressing was the moderate assist.  His endurance was limited.  PT reported Stan was able to get in and out of bed with minimal assistance.  He transferred via a lateral scoot with minimal assist. He was nonambulatory.  He propelled his wheelchair 150 feet with supervision.  Outpatient PT was recommended.

xxxx was discharged home with a very supportive wife who had undergone all family education.  She made adaptations to the house.  Discharge equipment included a hospital bed, wheelchair with cushion, bedside commode, and shower chair.  They planned on hiring an assistant to help with care at home.  Home health nursing, PT, OT and aide services were arranged.  Discharge activity was out-of-bed 2-3 times/day.  Stan was advised to wear his brace at all times when out of bed.  Discharge diagnoses:

• Pelvic fracture S/P ORIF
• Lumbar-sacral plexopathy with paraparesis
• Pelvic wound infections S/P irrigation and debridement
• T6 burst fracture S/P ORIF
• Upper GI bd
• Esophageal dilation
• Hematuria
• Heparin-induced thrombocytopenia
• Bilateral LE deep venous thrombosis
• Bilateral UE deep venous thrombosis
• IVC (inferior vena cava) filter placement
• MSSA bacteremia
• Anemia
• Chronic pain
• Debility

Currently, xxxx is receiving Physical Therapy through Home Nursing Inc.  3 X / week.  The script has to be renewed every 6 weeks.  The therapist is trying to move him to outpatient therapy, but with the IV medications he has been on, this has not been possible.  Therefore the therapist has been coming to the home for these sessions which last for an average of one hour each.  He continues on IV antibiotics for MSSA and in fact was on IV therapy throughout my evaluation.  He has an Infusaport in his left arm currently but his Mediport in the upper right chest was removed as a possible source of MSSA infection.  The physicians now believe that the hardware in his back may be a further source of the MSSA infection.  

The PT is still hoping to move him to outpatient therapy soon but every time they come he is recertified for another eight weeks of home-based therapy because of his condition.  He becomes worn out just trying to get into the car.  He rarely tries to get into a car except for his doctor’s appointments.  He expects an accessible van, on which he has a deposit, to be delivered in two weeks.

MEDICATIONS:

Medication	Strength	Frequency	Tablets Day	Purpose	Rx By:
Lexapro	10 mg	1/day	1	Depression	Spec
Protonix	40 mg		1	Stomach	Spec
Coumadin (2 dosages)	5 mg	2/week		Blood Thinner	Spec
Zanaflex	2 mg-4 mg	3/day		Muscle Pain	Spec
Lyrica	75 mg		3	Nerve Pain	Spec
Lopessor	25 mg	2/day		Blood Pressure
Duragesic Patch	25 mcg	Every 72 hours		Pain	Spec
Ambien	5 mg	1/night			Spec
Klonopin Wafer	.5 mg	4/day PRN (Only takes ½ tablet on occasion)		Anxiety	Spec
Medication	Strength	Frequency	Tablets Day	Purpose	Rx By:
Rifampin-(Thera-thorn)-	300 mg	2/day		Antibiotic	Samuels (from xxxx Regional)
Flomax
Coumadin	2.5 mg	3/week		Blood Thinner	Spec

Additional Medications/Notes:  (Spec)

There is a new medication (unsure of name) – and unsure of frequency.  Maybe twice per week to three times per week right now.  This was in conjunction with going off his Oxycontin and Methadone which was recently discontinued.

The IV Antibiotics are prescribed by Dr. Sara Till (Infectious disease specialist).

Over-the-Counter Medication(s):

• Senokot 1/2 tablet per day (Spec)
• Iron 3/25 mg 3/day (capsule)
• Miralax 1 capful 1/day.

PHYSICIANS / PROVIDERS:

Doctors _               Specialty _ Phone _ Fax Frequency Last Seen

xxxx, MD

PCP

xxx

xxx                        /2-3 weeks

05/22/12

xxxx (Coordinating all medical care.)  He has been taking care of all other issues and prescribing medications.

xxxx MD

Internal Med./Inf.

xxx

xxx

5/22/10

xxx.  Has been seeing her every two weeks, but hopefully, the MRSA will be cleared.

xxxx , MD

Neuro-surgeon

xxx

xxx

 

xxxx,MD

Surgeon

xxx

xxx

Will see to take out the MediPort (Removed the Groshong); xxx.  

COMPLICATIONS:

• Deep vein thrombosis
• Pneumonia
• Decubitus Ulcers
• Urinary Track Infections
• Contractures
• Infection
• Constipation

PAST MEDICAL HISTORY:

xxxx M.D.:  4/10/10

xxxx was evaluated for complaint of about two years of right shoulder pain present mostly when hitting backhand at tennis and was located over the bicipital tendon groove on the right shoulder.  Several years earlier, he had a much more serious problem and saw Dr. xxxx who prescribed PT that helped.  He played tennis approximately 5 days/week.  Past medical history was significant for colon polyps, hyperlipidemia, malignant Stananoma on back, treated in 2002 and abnormal resting EKG.  

Examination revealed tenderness over the right bicipital groove.  The subdeltoid bursa was tender on extension against resistance.  The area was injected with Decadron with immediate improvement.  Diagnosis: Probable  bicipital tendonitis with differential including subdeltoid bursitis and rotator cuff disease.  If no better in two weeks, MRI of the right shoulder would be ordered to rule out rotator cuff disease.

• Denies any prior history of accidents or injuries requiring medical care or treatment.
• No prior health conditions of a chronic nature for which he was being treated, (other than hypercholesterolemia and high blood pressure)
• No diabetes   
• No treatment by a psychologist or psychiatrist
• No psychotropic medications
• No history of drug or alcohol abuse.  
• Denies any drug or alcohol treatment programs.

Suzie believes that shock and medications that were being used caused him to react (DT’s) while under intubation and while reacting to the Iodine.  Stan and Suzie indicate he averaged a glass of wine with dinner and one additional cocktail each day.  It was common to go out with other couples on the island two or three times per week and on those occasions he would have one drink at home and another at the restaurant.  Suzie indicated three might be more likely but neither felt that heavy drinking on a regular basis was a pattern.  Suzie reported if/when he worked very hard or did physical work, this was followed by more than the usual drinks.  After a detailed discussion and very pointed questions they both deny alcoholism on his part.  No history of DUI charges are noted.

PSYCHOSOCIO/BEHAVIORAL:

Patient:  Per spouse:  “He is better in front of friends and family; at times he will let down with me and at times that is a reflection of my feelings.  He tries to be strong.  I think he is depressed as anyone would be because of this accident.  He sleeps a lot; he feels he has lost total control of his life.”

In clinical interview he admits to stress, tension, anxiety and depression.  He particularly feels this when the pain patch is wearing down toward the end and before a new patch is administered.  At those times he cannot get comfortable and his psychological responses to pain begins to increase.  

Family, Emotional Impact on Spouse/Children:  Suzie – “counseling has been suggested, but I look at it that I would have to drive 40 minutes to go talk to someone and drive back and the thought of it is too overwhelming.   People try to help [family, physicians], but going to counseling is just another thing that would have to be done.  I feel overwhelmed.  Depression comes and goes.  I did have medication for it but I decided I didn’t like to take the medication; I didn’t like the feeling of taking medication; I would rather have my cry every now and then.”

PHYSICAL / MENTAL CAPABILITIES/LIMITATIONS:  

Loss of Tactile Sensation:  Bilateral legs.  “Sometimes he asks me if his feet are covered.”  He cannot tell if he is warm or cold in his legs.

Reach:  Normal ROM without pain, except he lacks strength like before.  “He was always a very strong man.”

Lift:  It would be a struggle to lift a gallon of milk – maybe more awkward than actually limited by pain; he is limited by fatigue.  He continues wearing a clam-shell brace through August and then it will be assessed to see if he needs it further.  It was recommended he wear the brace for one year.

Prehensile/Grip:  Much weaker than before.  He is functional, but just not as strong.

Sitting:  Tolerance at this point is a little under four hours, only in his reclining wheelchair.  He is unable to get into and out of a La-Z-Boy type recliner.  He is working on trying to make standing pivot transfers, but this is very physically taxing.  

Standing:  Not functional; he is just starting to do some standing exercises in therapy.  A standing frame was purchased and he has been in that since January 2007; he tries to stand 30-40 minutes every day if possible.

Walking/Gait:  N/A – just starting to work on standing pivot transfers.

Bend/Twist:  He is wearing a clam-shell brace so this is not assessable.

Kneel:  Not functional.

Stoop/Squat:  Not functional.

Climb:  Not functional.

Balance:  Unable to assess at this point.

Breathing:  Unable to assess because of clam-shell and the fact that he stays in bed most of the time.  “He has had pneumonia, so we have to make sure he takes deep breaths and uses a spirometer.”

Headaches:  Occasionally, none before.  Difficult to take pain medications because he is on Coumadin.  Suzie thinks this is more generalized pain.

Vision:  Recent new prescription for reading.

Hearing:  Intact conversationally.

Driving:  Not able to drive at this time; he has not been assessed to drive. They just purchased a wheelchair accessible van but at the time of the evaluation, this had not yet been delivered.  

Physical Stamina (average daily need for rest or reclining):  Very fatigued.  He spends about 10-12 hours per day in bed actually sping.  He is in bed about 20 hours per day and he does a lot of dozing.  They have attempted to get a computer he can use in bed, but he prefers to use the computer while in the wheelchair.

EDUCATION:

Highest Grade Completed:  University of xxxx, Degree, xxxx School, University of Washington, 1970

EMPLOYMENT/WORK HISTORY:

Released to Return to Work:  N/A

Work History Since Injury:  N/A

Retired from the xxx industry in 2005.

Military – Branch:  Coast Guard

Service Dates:  6 months, plus 6 years reserve status.

FINANCIAL:

Current Financial Situation:  Since the injury, they have paid to put in a ramp and put in doors to shut off the garage to store his medical equipment.  In the house the doorways are barely wide enough.  Shower doors were taken off, but because of his clam-shell brace, he cannot access.  They will need a ramp built to allow access to the shower, however.  She has had the doors that lead to the bathroom removed.

Medicare:  “He has used up his life time Medicare.  He can return to the hospital for the same condition but he must wait for sixty days before he can go in again.  Only private insurance is a supplement to Medicare.”

Other Agency Involvement : State Vocational Rehabilitation:  No.

State Employment Services:  No.

Rehabilitation Nurse:  No.

Other Agency:  No.

Felony Convictions?  No.

TESTS ADMINISTERED:

As part of this evaluation, Stan is asked to complete the Beck Depression Inventory-II; the Beck Anxiety Inventory; the Beck Hopelessness Scale and the Minnesota Multiphasic Personality Inventory-2, (MMPI-2).

On the Beck Depression Inventory-II, Stan’s score of fourteen just reaches clinically significant levels.  This is consistent with the clinically elevated depression scale he demonstrates on the MMPI-2.  Clinical interview and test results are consistent with DSM-IV-TR criteria for a finding of Major Depression-Single episode-Moderate.

On the Beck Anxiety Inventory, his score of thirty-eight does indicate a severe clinical anxiety.  This is consistent with findings on his MMPI-2. Clinical interview and test results do meet DSM-IV-TR criteria for a finding of General Anxiety Disorder-300.02.

On the Beck Hopelessness Scale, his score of zero suggests an optimistic outlook on his future.  Research indicates scores of nine or more are predictive of eventual suicide in depressed suicidal ideators.  Research also indicates the Hopelessness Scale is far more predictive of suicidal tendencies in the future than the results of the depression scale, and must be used in conjunction with clinical interview for more accurate results.  His results on this scale are also consistent with his MMPI-2 results.  Stan appears to be coping at a basic level with many of the psychological issues stemming from his disability, at least in the sense that he does not appear suicidal or self-destructive.  I do not glean any suicidal ideation from clinical interview or test results.

On the MMPI-2, a valid profile is obtained based on a review of the validity scales.  Consideration is first given to the VRIN (variable response inconsistency) and TRIN (true response inconsistency) sub-scales, which used paired responses of similar and opposite items to measure inconsistencies in response patterns.  An inconsistent response pattern represented by significantly elevated T-scores, invalidates the profile.  In Stan’s case, the T-scores are within normal limits.  Next, I evaluated the F, F sub b and F sub p scales, which represent infrequently endorsed items that are sensitive to random and fixed responding.  Again, significantly elevated T-scores will invalidate the MMPI-2 results. xxxx’s T-scores are well within normal limits.  

Finally I reviewed the L, K and S scales.  In this instance, T-scores greater than 79 on the L scale, 75 on the K scale and 70 on the S scale tend to reflect individuals who are demonstrating protocols characterized by a pervasive pattern of nonacquiescence.  This is a pattern often referred to as a “fake good” profile.  The individual is trying to present a better picture of them self than actually exists. Stan’s scores do not exceed these parameters; therefore, his MMPI-2 is considered valid.  There is no evidence of impression management and no indication of either “fake good” or “fake bad” profiles.  He shows no indication of malingering in his clinical scales.  

xxxx does demonstrate a significantly elevated triad profile with scale three, hysterical/anxiety response to disability at the peak followed by scale one, somatic focus.  This is followed by a clinically elevated scale two, depression, forming an elevated triad pattern, which represents a classic chronic disability/chronic pain profile consistent with exposure to severe disability and pain over time.  Stan also reaches clinical significance on scale 8.  Persons with this profile are often described as having a lot of physical complaints, having feelings of insecurity, inadequacy and inferiority.  Often these feelings stem from a lowered sense of self-worth and body worth.  Stan may ruminate excessively about self-worth post onset of disability.  He may be experiencing an identity crisis characterized by a lack of personal direction.  He likely has underlying feelings of inadequacy and worthlessness.

Axis I: Chronic Disability/Chronic Pain Disorder due to general medical condition and psychological factors-307.89

Adjustment Disorder with depressed mood-309.0.

Generalized Anxiety Disorder-300.02.

Major Depressive Disorder-Single Episode-Severe-296.23.

Axis II: Deferred.

Axis III: Pelvic fracture S/P ORIF

Lumbar-sacral plexopathy with paraparesis

Pelvic wound infections S/P irrigation and debridement

T6 burst fracture S/P ORIF

Upper GI bleed

Esophageal dilation

Hematuria

Heparin induced thrombocytopenia

Bilateral LE deep venous thrombosis

Bilateral UE deep venous thrombosis

IVC (inferior vena cava) filter placement

MSSA bacteremia

Anemia

Chronic pain

Debility

Probable bicipital tendonitis with differential including subdeltoid bursitis and rotator cuff disease

Axis IV: Life Stressors secondary to disability and psychological response to exposure to disability.

Axis V: Current  GAF – 51.

Highest GAF in past year – 51.

CONCLUSIONS:

Careful consideration has been given to all of the medical, psychosocial, and rehabilitation/mental health counseling data contained within this file and my report.  Stan remains significantly disabled secondary to the 5/1/10 event and subsequent complications.  He is nonfunctional for independent living skills, and it is anticipated that he will remain very dependent throughout the remainder of his life.

A Life Care Plan has been prepared for xxxx, and is attached as Appendix “A”.  A Life Care Plan is a dynamic document based upon published standards of practice, comprehensive assessment, data analysis, and research, which provides an organized, concise plan for current and future needs, with associated costs, for individuals who have experienced catastrophic injury or have chronic health care needs.  (IALCP – International Academy of Life Care Planners, 2003. Definition established during the 2000 Life Care Planning Summit)

Through the development of a comprehensive Life Care Plan, a clear, concise, and sensible presentation of the complex requirements of the patient are identified as a means of documenting current and future medical needs for individuals who have experienced catastrophic injury or have chronic health care needs.  The goals of a comprehensive Life Care Plan are to: improve and maintain the clinical state of the patient; prevent secondary complications; provide the clinical and physical environment for optimal recovery; provide support for the family; and to provide a disability management program aimed at preventing unnecessary complications and minimizing the long-term care needs of the patient.  The main avoidable complications requiring careful monitoring and appropriate preventative and treatment programs are: bladder and renal tract complications; constipation or diarrhea; under nutrition; respiratory infections; stress ulceration; deep vein thrombophlebitis; decubitus ulceration; complications of medications and disruption of family dynamics.

The Life Care Plan outlines all of xxxx’s needs dictated by the onset of disability throughout his life expectancy.  In addition to the recommendations specifically for xxxx adjusting to his disability and becoming a better disability manager.  At no time in this Life Care Plan, however, do we rely solely upon xxxxxxxxxxxxx to provide supportive intervention.  Should xxxxxxxxxxx choose to provide services, these services have a value, and the best way to determine this value is to indicate what those services would cost on the open labor market.  These are identified in the Life Care Plan.

xxxx will require care and support for the remainder of his life expectancy.  His needs are dictated primarily from his level of disability, but also his care needs due to the age of onset are a factor in his achieving more independence.  Stan does not generally fit into the typical literature and statistics on aging with disability, since he acquired his disability at an older age (age 68) and most literature on aging with disability describes the effect of aging on injuries of 20 years or more.  However, literature does indicate that persons older at the time of injury experience loss in function sooner than persons who were younger when the SCI occurred.1

Loss of function, pain, musculoskeletal problems, declining energy and loss of strength are examples of new challenges people face whether they are aging with or without a SCI.  With the onset of these symptoms, activities such as transferring, bathing, dressing, propelling a wheelchair, performing chores, working a full day, socializing and participating in recreation become more difficult and sometimes impossible to continue.  Functional changes can result in the need for additional help with activities that once were performed independently.  Needs for new equipment and specialty medical and rehabilitative services often arise.2

These changes suggest a limited reserve capacity, less resiliency, or a lower tolerance to health changes in the older population.  These data suggest that acute rehabilitation of older adults with SCI should focus on garnering resources and preparing for a level of function that may not be sustained for a long period of time.  The effect of fatigue, pain and weakness on activities of daily living is increased in the non-disabled population with aging, much more so in the disabled population.  Persons with incomplete injuries had more fatigue, lower endurance, new muscle weakness and twice the incidence of pain compared to those with complete injuries.3  These data suggest that an interactive effect may exist between level and completeness of injury and the occurrence of fatigue.4

In addition to considering the research literature on spinal cord injury, attention is paid to the Clinical Practice Guidelines for spinal cord injury promulgated by multiple sources and cited in the Life Care Plan. Letters to all of xxxx’s treating physicians were sent along with questions to each for their long term care recommendations.  All of these steps are taken to help in establishing the medical foundation in addition to the case management and Life Care Planning foundations for the Plan.

As xxxx was retired at the time of this injury, no report outlining any vocational impact resulting from this injury has been completed.

After you have had an opportunity to review this narrative report and the attached appendix, please do not hesitate to contact me should you have further questions.

Respectfully Submitted,

xxxx, RN, CCM, CPUR, CLCP

Footnotes:

Attachment: Appendix A:  Life Care Plan

Footnotes:

1. (Source:  Thompson, L., Functional changes in persons aging with spinal cord injury.  Assistive Technology: 1999; 11:123-129, as cited in Topics in Spinal Cord Injury Rehabilitation: Aging with Spinal Cord Injury.  Kemp, Bryan, and Adkins, Rodney, H., Thomas Land Publication, Volume 6, No. 5, Winter 2001.)
2. Kemp, B., & Thompson, L. (2002).  Aging and SCI:  Medical, functional, and psychological changes.  SCI Nursing, 19(2), 51-60.
3. (Source: Katz, K., Branch, L.G., Branson, M.H. Active Life Expectancy.  New England Journal of Medicine, 1983: 309:1218-1224, as cited in Topics in Spinal Cord Injury Rehabilitation: Aging with Spinal Cord Injury.  Kemp, Bryan, and Adkins, Rodney, H., Thomas Land Publication, Volume 6, No. 5, Winter 2001.)
4. (Source:  Gerhart, K.A., Charlifue, S.W., Weizenkamp, D.A. Mild and Incomplete Spinal Cord Injuries:  A walk in the park?  SCI Life. 2000; Winter: 24-25.  As cited in Topics in Spinal Cord Injury Rehabilitation: Aging with Spinal Cord Injury.  Kemp, Bryan, and Adkins, Rodney, H., Thomas Land Publication, Volume

NOTES:

• All costs are estimated, unless stated otherwise.
• All costs are based on today’s 2010 dollars without regard for inflation, cost-of-living increases, or other economic considerations.
• All growth trends to be determined by an economist.
• This Life Care Plan report should be viewed as preliminary in the event further medical information would be forthcoming.

PROJECTED EVALUATIONS

Service	Specialty	Frequency	Base Cost	Annual Cost	Resources
Occupational Therapy	Occupational Therapist	Evaluation	$300.00 per session	$300.00 year 2012→LE	xxxx
Physical Therapy	Physical Therapist	Evaluation	$300.00 per session	$300.00 year 2012→LE	xxxx
Memorial Transitional Rehab (Initial)	Outpatient Rehabilitation	Evaluation	$1500.00 2 day session	$1500.00 year 2012
Memorial Transitional Rehab (Annual SCI Re-Evaluation)	Outpatient Rehabilitation	Evaluation	$1500.00 2 day session	$1500.00 year 2012→LE	xxxx
John Edwards, MD	PMR	1 x per year	$150.00	$150.00 year 2012→LE	Dr. xxxx Office
Malcolm Ghazal, MD	Orthopedist	1 x per year	$165.00	$165.00 year 2012→LE	Dr. xxxx
Urology Associates	Urology	1 x per year	$150.00	$150.00 year 2012→LE	Urology Associates
Carol L Penn, MD	Psychiatrist	Evaluation	$200.00 per session	$200.00 year 2012→LE	Dr. xxxx
Dietary Directions	Registered Dietician	1 x per year Evaluation	$175.00	$175.00 year 2012→LE	Dietary Directions
Craig Aaronson, DPM	Podiatrist	1 x per year Eval & Visit	$112.00	$112.00 year 2012→LE	Dr. xxxx
Community Rehabilitation	Adaptive Vehicle Evaluation	Evaluation	$1000.00	$1000.00 year 2012→LE	xxxx
Community Rehabilitation	Final Inspection	Evaluation	$750.00	$750.00 year 2012→LE	xxxx
Home Accessibility	Home Accessibility Evaluation	Evaluation	$1000.00 to include both homes.	1 x charge will apply to construction.	xxxx
Recreational Therapy	Recreational Therapist	Evaluation	$175.00	$175.00 year 2012→LE	Therapy Dynamics

* Year 2009:$5977.00

Year 2012→LE$4977.00

Memorial Transitional Rehabilitation includes yearly exam with physician that specialized in spinal cord injuries.

Therapists are professionals who have training end expertise in clinically recognized areas.  All practicing therapists must pass standardized tests and be certified or licensed in    their field.  Qualified therapist have a working knowledge of assistive technology foundations, devices, and applications and can complete a formal assessment see: Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury—1990–1997*1, *2 Archives of Physical Medicine and Rehabilitation, Volume 80, Issue 11, Pages 1457-1463 E.Eastwood, K.Hagglund, K.Ragnarsson, W.Gordon, R.Marino

THERAPIES

Service	Frequency	Base Cost	Annual Cost	Resources
Occupational Therapy	3 sessions per year	$300.00 per session	$900.00 year 2012→LE	Community Outpatient Rehabilitation Center
Physical Therapy	3 sessions per year	$300.00 per session	$900.00 year 2012→LE	Community Outpatient Rehabilitation Center
xxxx Transitional Rehab	5 days per week Year 2010	$685.00/day x3 month program	$61650.00 year 2010	xxxx
xxxx Transitional Rehab	5 visits per year Years 2012→LE	$685.00/day	$3425.00 year 2012→LE	xxxx

*Physical therapy to start year of 2012 following extensive outpatient therapy program for home evaluation and assessment of ADL’s.

Year 2012:$ 5225.00

Year 2012→LE: $63,450.00  

Patient to have 3 additional PT & OT visits per year to assess mobility status and reinforce home exercise program, following a yearly 5 day aggressive outpatient therapy program.  As people age they will require yearly assessments, treatments and education on assistive devices, home exercise programs, and adaption: ncbi.nlm.nih.gov.sites/entrez also see: Source:  Winter: 24-25.  As cited in Topics in Spinal Cord Injury Rehabilitation:  Aging with Spinal Cord Injury.  Kemp, Bryan, and Adkins, Rodney, H., Thomas Land Publication

PHYSICIAN APPOINTMENTS

Physician	Specialty	Frequency of Visits	Cost per visit	Annual Cost	Resources
xxxx, MD	PCP	Every 3 weeks x 3 months 4 per year thereafter	$105.00	$735.00 year 2012 $420.00 year 2013 →LE
xxxx MD	Infectious Disease	Every 2 weeks x 2 months	$105.00	$420.00 year 2012
xxxx, MD	Neurosurgeon	4 x per year x 1 year 2 x per year x 2nd year 1 x per year thereafter	$155.00 $155.00 $155.00	6420.00 year 2012 $310.00 year 2013 $155.00 year 2014→LE
xxxx, MD	Surgeon	1 x visit for removal of mediport	$135.00 + procedure fee	$135.00 year 20012
xxxx	Psychiatrist/Individual counseling	Year 11x per week x48 weeks Year 2 2x per month x12 months Year 3→LE 4x per year	$175.00	$700.00 year 2012 $4200.00 year 2013 $700.00 year 2014→LE	Dr. xxxx
xxxx	Psychiatrist/Family counseling	2x per month x 6 months	$175.00	$2100.00 year 2012	Dr. xxxx

*Pricing obtained from each individual physician.

 Year 2012: $10375.00

 Year 2013: $4930.00

 Year 2014→LE: $1275.00

On going therapy will be required as change in mobility can destroy the quality of life resulting in disturbing sleep and appetite, creating fatigue.  Patients who have a SCI should receive treatment and should be evaluated for anxiety and distress.  Major depression is a common psychiatric comorbidity of SCI: ncbi.nlm.nih.gov/sites/entrez.

Family counseling to assist family/spouse in making adjustments to the injuries and provide on going support for the spouse to prevent caregiver burnout.

MEDICATIONS

Medication	Dose/Frequency/Route	Base Cost	Per # tabs/pills	Annual Cost	Resources
Lexapro	10mg/1 per day/p.o.	$237.97	90	$951.88 year 2012→LE	Drugstore.com
Protonix	40mg/1per day/p.o.	$368.87	90	$1475.48 year 2012→LE	Drugstore.com
Coumadin	5m/2 per wk/p.o.	$11.19	24	$44.76 year 2012→LE	Drugstore.com
Coumadin	2.5mg/3 per wk/p.o.	$17.99	36	$71.96 year 2012→LE	Drugstore.com
Zanaflex	2-4mg/3 per day/p.o.	$447.17	252	$1788.68 year 2012→LE	Drugstore.com
Lyrica	75mg/3 per day/p.o.	$579.56	270	$2318.24 year 2012→LE	Drugstore.com
Lopressor	25mg/ 2 per day/p.o	$31.93	180	$127.72 year 2012→LE	Drugstore.com
Duragesic Patch	25mcg/every 72 hours	$624.64/box	6 boxes	$2498.56 year 2012→LE	Drugstore.com
Ambien	5mg/1 per noc/p.o.	$446.88	90	$1787.52 year 2012→LE	Drugstore.com
Klonopin Wafer	0.5mg/4 per day PRN	$831.89	360	$3327.56 year 2012→LE	Drugstore.com
Rifampin	300mg/2 per day/p.o.	$351.94	180	$351.94 3 months only	Drugstore.com
Flomax	0.4 mg 24 hr cap	$$307.40	90	$1229.60 year 2012→LE	Drugstore.com
Senokot	½ tab per day/p.o.	$24.49/bottle	100	$48.98 year 2012→LE	Drugstore.com
Iron	3/25 mg/3 cap per day/p.o.	$12.99/bottle	60/bottle	$77.94 year 2012→LE	Walgreens.com
Miralax	1 cap per day/p.o.	$34.05/bottle	1 bottle	$408.50 year 2012→LE	Americaprescription.com

*This regime is based on current medications and does not reflect complications.

 Year 2012: $16,509.32

 Year 2013→LE: $16,157.38

MOBILITY

SERVICE	REPLACEMENT	BASE COST	ANNUAL COST	RESOURCES
Electric Wheel Chair: Pronto M41 Semi-Reclined Seat	Every 5 years Begin Year 2012	$5656.00		Invacare
Electric Wheel Chair Battery	Yearly beginning 2012	$114.00	$114.00	xxxx
Bearings	Yearly beginning 2012	$23.00/each	$46.00	xxxx
Casters	Yearly beginning 2012	$55.00	$55.00	xxxx
Seat cushion	Yearly	$64.99	$64.99 year 2012→LE	xxxx
Joy Stick	As needed begin year 2012	$1500.00		xxxx
Arm Rests	Every 2 Years beginning 2012	$55.00/each		xxxx
Maintenance	Yearly beginning 2013	$75.00/hour billed in 15 minute segments	$75.00	xxxx
Manual Wheel Chair: Quickie LXI Lightweight	Every 5 years Begin Year 2012	$849.00		xxxx
Break Adjustments	Adjustment of breaks with tire and wheels checked beginning 2013	$200.00		xxxx
Wheels	Yearly beginning 2013	$100.00/pair	$100.00	xxxx
Breaks	Yearly beginning 2013	$15.00/each	$30.00	xxxx
Maintenance	Yearly beginning 2013	$60.00/hour	$60.00	xxxx
Cushions for Wheelchair	Yearly	$79.00	$79.00 year 2009→LE	xxxx
Power Hoyer Lift	Every 10 years begin 2012	1329.00		xxxx
Hoyer Sling	Every 5 years begin 2012	$66.00		xxxx
Pool Lift with sling	Every 10 years begin 2012	$925.00		xxxx
Surface Mount Pool Adapter	Every 10 years begin 2012	$223.32		xxxx
Walker with Seat	Every 10 years begin 2012	$145.00		xxxx
Floor Mounted Parallel Bars	Every 10 years begin 2012	$845.00		xxxx
Aqua Jogger	Every 5 years begin 2012	$65.00		xxxx
AFO	Every 5 years begin 2012	$48.00 for 1		xxxx
5 Foot single fold ramp	Every 10 years begin 2012	$162.00		xxxx
Easy Stand Evolve Standing Frame	Every 10 years begin 2012	$2775.00		xxxx
Maintance Evolve Frame	Yearly beginning 2013	$100.00	$100.00 year 2010→LE	xxxx

* Assistive technology is any item, piece of equipment, or system, whether acquired commercially, modified or customized, that is commonly used to increase, maintain, or improve functional capabilities of individuals with disabilities: sci-info-pages.com/adaptive.html also see Disability and Rehabilitation, Volume 23, Number 9, 15 June 2001, pp. 387-393 (7)

MEDICAL SUPPLIES

SERVICE	REPLACEMENT	BASE COST	ANNUAL COST	RESOURCES
Chux (Bed Pads)	Every 2 months	$34.95/100	$277.04	xxxx
Urinal	48/year	$4.95/Each	$237.60	xxxx
Gloves	Every 6 months	$6.75	$13.50	xxxx
Triple Antibiotic Ointment	2 tubes per year	$4.49	$8.98	xxxx
Band-aids	2 boxes per year	$7.99	$15.98	xxxx
Moisturizer Creams	3 bottles per year	$6.49	$19.47	xxxx
Drugstore.com	4 packages per year	$4.99	$19.96	xxxx
Drugstore.com	As needed	$19.99		xxxx
Wal Mart	100/Pkg 2 per year	$2.99	$5.58	xxxx

* Year 2012→LE $598.11

Mr. xxxx will require the above following medical supplies.

AIDS

SERVICE	REPLACEMENT	BASE COST	ANNUAL COST	RESOURCES
Enviromental Control Unit	1x charge	$6500.00	$13,000.00 year 2012	xxxx
Maintaince Upgrade	Yearly begin 2013	$400.00	$400 year 2013→LE
32” Reacher	Every 5 Years begin 2012	$22.49		xxxx
Transfer Boards	Every 5 years begin 2012	$28.50		xxxx

* Mr. xxxx will require the environmental control unit that will help him to maintain independence in his home; d/t having 2 homes he will require 2 units: assistivetechnoliges.com/gallery.asp?category=12&CT=EADL%FECU see also The Lancet, Volume 359, Issue 9304, Pages 417-425 J.McDonald, C. Sadowsky

AIDS FOR BATHROOM

SERVICE	REPLACEMENT	BASE COST	ANNUAL COST	RESOURCES
Safety Rails	Every 5 years	$40.00/for 2		xxxx
Hand Held Shower Hose	Every 5	$45.00		xxxx
Shower Wheel Chair all In One	Every 5 Years	$587.00		xxxx

* Beginning year 2012 $672.00 then every 5 years

Mr. Manly will require 2 sets as he maintains 2 homes.  The equipment will provide him safety while bathing.

AIDS FOR BEDROOM

SERVICE	REPLACEMENT	BASE COST	ANNUAL COST	RESOURCES
Electric Queen Bed	Bed: $5599.00 Shipping: $400.00 Every 10 years	$5999.00		xxxx
Upper Bed Rails	Every 10 Years	$449.00/Pair		xxxx
Specialty mattress	Every 10 years	$1295.00		xxxx

* Year 2012: $7743.00 then every 10 years thereafter.

Mr. xxxx require 2 sets one for each home, the specialty mattress will help to prevent future decubitus ulcers which is a common complication of spinal cord injuries.

Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2000.

AIDS FOR DRESSING

SERVICE	REPLACEMENT	BASE COST	ANNUAL COST	RESOURCES
Daily care kit (includes shoe horn & dressing stick)	Every 5 years	$29.45		xxxx

* Year 2012 $29.45 then every 5 years.

The daily care kit will assist Mr. xxxx so he will not always require another person for assistance.

DIAGNOSTIC TESTING

Service	Frequency	Base Cost	Annual Cost	Resources
Urinalysis with C&S	1 time per year	$84.75	$84.75	xxxx
Comprehensive Metabolic Panel	1 time per year	$42.00	$42.00	xxxx
CBC	1 time per year	$42.00	$42.00	xxxx
MRI – Lumbar	Every 2 years	$1100		xxxx
X-Rays – Lumbar	1 time per year	$150.00	$150.00	xxxx
EKG	1 time per year	$67.50	$67.50	xxxx

*Year 2012→LE for odd years only:  $1486.25

 Year 2013→LE for even years only: $386.25

Diagnostics needed to monitor the patients functional status and diagnostic purposes.

A spinal cord injury can affect most organ systems of the body.  The most frequent complication is related to skin; however, pulmonary and urologic complications are often more threatening and serious for the individual with spinal cord injury: spinalcord.uab.edu/show?durki=32106

HOME CARE/CASE MANAGEMENT

Service	Frequency	Base Cost	Annual Cost	Resources
Case Management	10 hours 1st month 2 hours per month thereafter	$90.00/hr	$2880.00 1st year $2160.00 each year there after	xxxx
Personal Care Attendant	40 hours per week	$25.00/hr	$52000.00	xxxx

*Year 2012: $54,880.00

 Year 2013→LE: $54,160.00

In research there is very little cost difference between private hire and agency hire, however agency hire employees are bonded and furnished liability benefits from the employer releasing Mr. Manly and his family from any liability.

AIDS FOR TRANSPORTATION

Service	Frequency	Base Cost	Annual Cost	Resources
Power Lift	10 years	$8500.00		xxxx
Maintenance	Every 6 months	$100.00/hr	$200.00	xxxx
Adaption Van with W/C lift tie downs	Every 10 years Beginning 2019	$51820.00		xxxx

*Year 2012: $8500.00

 Year 2013→2018: 200.00

 Year 2022: $60,320.00

 Year 2021→LE: $200.00

Patient currently has a van on purchase and is not included in this life care plan.

Technology plays an important role in every aspect of daily life. To get from one place to another, most people use automobiles or public transportation, Technology plays an even more significant role in the life of someone with a severe disability such as a spinal cord injury (SCI). SCI can have a major effect on virtually all aspects of one’s life. Products and devices designed to increase an individual’s level of function and independence can be instrumental in providing a person with SCI the highest possible level of function after injury see: abledata.com/abledata_docs/icg-spin.htm

NOTE: The purpose of the Life Care Plan is to recommend preventative services in order to avoid complications.