CV: A Case Study

A review of his medical records indicates that he had his first CVA later March of 2016 then one week later he had another CVA. His last CVA resulted in a stay in ICU with a tracheostomy and peg tube placement. He no longer has a tracheostomy and he recently loss his peg tube and refused to have it replaced. He was recently hospitalized at SLMC with complaints of fatigue and neck pain. He suffers from co-morbidities of DM which is stable with insulin, HTN which is stable and hyperlipidemia which is stable.
At todays visit he is accompanied by his wife. He is awake but unable to speak due to the effect of his last CVA. The wife provides his history. She reports that he has increased poor appetite with weight loss. He used to be in the 140lb

but now he is 109lb. He refused peg tube placement. She reports that he eat a puree diet but refused thicken liquid. She states that he does not cough when he eats but cough severely when he drinks. There is a strong possibility that he is aspirating and is at an increased risk of developing aspiration pneumonia. She reports that he complains of neck and back pain daily. His pain does not radiate, His pain is worse when he sits in one position too long. In the hospital he was taking Percocet but was not discharged with any pain medication. According to the face scale his pain is a 4/10 in severity. He has chronic neuropathy that is diabetic related. He does have a history of toes amputation resulting from his diabetes. His wife monitors is blood sugar and administer his insulin. She reports that he is nonambulatory and is total with his ADLS. She states a wheelchair was ordered for him and she is waiting for it to be deliver. He has a hospital bed in place. He is active with a home health agency that provides Sn, with therapy schedule to start tomorrow.