Maribel Case Summary

Choking/Aspiration-Medium Risk: Maribel did not have any choking or aspiration episodes within the past year; MBSS completed on 6/24/16 with no hanges on diet consistency. She continues on regular diet texture with deboned meats and cut finger foods in quarters; thin liquids. Takes medications whole follwed by sips of water. Supports have been effective. Respiratory Compromise-Medium Risk: Maribel has not had any respiratory problems; no ingestion of objects have been reported within the past year. Seasonal Influenza vaccine was administered on 9/21/16; last TB screening (QFT) on 11/31/15 was negative.

Dental-Medium risk: Maribel was seen in the outpatient setting for Dental rehabilitation on 05/19/16; patient tolerated procedure well and recover w/o complications; she continues with dental monthly rehearsals and SAP for
Refer to medication changes throughout the year in the following notes.
Last QMR 6/8/16 increased Zyprexa from 15 mg to 20 mg oral daily at bedtime. If improve will taper Depakote secondary to low therapeutic, possible causing hyponatremia and neutropenia. Depakote was indeed decrease on 9/4/16 from 750 mg to 500 mg oral daily at bedtime. Psychotropic meds continue being adjusted as per patient’s response; the goal is to decrease poly-pharmacy as well as to find the optimal doses and treatment for client mental health/stability.
Last pharmacy QDRR on 7/22/16 indicates psychotropic poly-pharmacy (Olanzapine, VPA and Clonazepam); patient is not free of potential drug-drug interaction (Olanzapine+VPA may result in decreased VPA concentrations; Furosemide+Lisinopril may result in orthostasis.
Last Moses and Discus 9/28/16 total score of 8 (2 agitation, 1 Irritability) Discus with total scores of zero, no TD