CASE 1    |    Sierra Burnes

CASE 2    |    Shirley Carter

CASE 3    |    Bradley Leonard (Butch) Sampson

CASE 4    |    Henry and Ertha Williams

CASE 5    |    Sherman (Red) Yoder

CASE 6    |    Charles Robert (Chip) Jones


CASE 8    |   Mrs. Millie Larsen

CASE 9    |    Ms. Julia Morales

CASE 10    |    Miss Patricia Verloren

CASE 11    |    Abel 

CASE 12    |    Heddy

CASE 13    |    NAME

CASE 14    |    NAME

CASE 15    |    NAME

CASE 16    |    NAME

CASE 17    |    NAME

Hospital Care

Mrs Larsen’s Hospital Stay

PictureMrs Larsen was admitted to Banner Boswell Medical Center, Sun City Arizona with a diagnosis of confusion and urinary tract infection.
Banner Boswell Medical Center is a nonprofit, 501-bed hospital providing medical care services including specialties in cardiac care, neurosciences, orthopedics, rehabilitation and oncology.

Banner Boswell Medical Center’s website describes it as a supportive environment that “encourages family and friends to participate in the healing process”. 

Click here for more information on the Banner Boswell Medical Center.

Case Notes

Physician and Physician Assistant 

Admit H&P

Name: Millie Larsen

Ms. Larsen was admitted to the Emergency Department after being brought in by her daughter became who stopped by and found her still in her bathrobe at 5:00 PM. Ms Larsen was confused to the point that she could not remember her daughter’s name. Millie was brought to the emergency department by her daughter and spent the night there before being admitted to the general medical-surgical unit around 9:30 AM.

Review Of Systems:
General: no fatigue, weight loss or gain, fever, chills, or night sweats
Eyes: no visual changes, pain or redness
ENT: occasional throbbing headaches (bi-temporal) lasting 1-2 hours and relieved with APAP or IBU, no hoarseness, no sore throat, no epistaxis, no sinus symptoms, no hearing loss or tinnitus
CV: no chest pain, edema, PND, orthopnea, palpitations or claudication
Resp: No cough, SOB, wheezing
GI: No abdominal pain, stool changes, nausea/vomiting, diarrhea, constipation, heartburn or blood in stool
GU: No dysuria, frequency, hematuria, vaginal discharge. Postmenopausal. Has had occasional urinary incontinence following coughing and laughing for past year.
Musculoskeletal: Pain in both knees, worse in evening after working/walking all day, no joint swelling or redness, no myalgias, no back pain.
Heme/Lymph: No abnormal bleeding or bruising, no transfusions or lymph node swelling.

HTN since 2000
Hypercholesterolemia- diagnosed September 2015
Glaucoma since 2005
Postmenopausal- LNMP 1975
Osteoarthritis- both knees
Stress incontinence x 1 years

Past Surgical HX:
- Cholecystectomy at age 30 

Family HX:
Spouse- Deceased, age 91
Daughter- Age 50, alive and healthy, named Dina
3 Grandkids- age 17, 14 and 12- alive and healthy

Social HX:
Widow, married 68 years, husband died 2014
Active in Lutheran church choir and kitchen
Pets; 1 cat (Snuggles)
Hobbies: gardening, cooking
Never smoked, drank ETOH or used illicit drugs


  • Captopril 25 mg po three times a day
  • Metoprolol 100 mg every day
  • Furosemide 40 mg po twice per day
  • Lipitor 50 mg once daily
  • Pilocarpine eye drops 2 drops each eye 4 times a day
  • Celebrex 200 mg po once a day
  • Tramadol 50 mg po every 4-6 hours prn pain

Allergies: - NKDA

Immunizations: - Influenza and Pneumococcal- 2013

Physical Exam:

- Alert and oriented x 3, does not remember confusion incident yesterday
- BP: 152/94, P. 64 and regular, R. 14 and unlabored, T. 98.2F, weight: 48Kg, height: 61 inches, BMI=20

Scalp: atraumatic, hair normal pattern, texture and distribution
Eyes: PERRLA, fundi without AV nicking or exudates, no obvious papilledema
Ears: EACs clear and atraumatic, TMs pearly grey and translucent, hearing grossly intact to voice and whisper
Nose: nares patent bilaterally, septum intact, no discharge, polyps or bleeding
Mouth: Edentulous with upper and lower dentures, gums intact without redness or lesions, oral mucosa somewhat dry, pharyx non-erythematous without exudate, uvula midline
Neck: supple, full and nontender ROM, no bruits, no lymphadenopathy, no thyromegaly
Chest: symmetric and nontender with normal AP diameter
Lungs: clear to auscultation bilaterally, no abnormal lung sounds
Heart: rate and rhythm regular, no murmurs, rubs or gallos
Abdomen: Soft and nontender, well-healed surgical scar upper right quadrant, bowel sounds normoactive, no hepatosplenomegaly
GU: deferred
BACK: Full ROM, no spinal tenderness, no CVA tenderness
EXTS: upper and lower extremities with grossly full ROM. No joint swelling, pulses 4+ and equal bilaterally. No calf tenderness. Both knees painful with ROM with mild crepitus.

LABS from ED:

UA: Color: dark amber, cloudy

  • Specific gravity: 1.050 (normal 1.005-1.035)
  • ph 6.0 (normal 4.5-8.0)
  • Pro: neg
  • Urobili: 1.0
  • Nit: Pos
  • Leu: Pos
  • Urine Micro:
  • RBC - 9 (normal 0-2)
  • WBC - 150,000 (normal 0-5)

Basic Metabolic Panel

  • Na – 149 mmol/L
  • K - 3.5 mmol/L
  • Glucose  - 105 mg/dL
  • CBC
  • Hgb: 9.9 mmol/L
  • Hematocrit: 32 %
  • MCV: 72 fL
  • MCHC: 29 g/dL
  • WBC 12,000 


  1. Acute confusional episode
  2. Mild dehydration
  3. Urinary tract infection
  4. Hypertension- uncontrolled
  5. Postmenopausal
  6. Osteoarthritis
  7. Stress incontinence
  8. Glaucoma



1) Admit to 6E
2) Out of bed with assistance
3) Regular, low-fat diet
4) IV fluids D5 .45 NaCl 20 mEq KCL at 60ml/hr

5) I&Os, vitals q shift
6) Continue home meds:


  • Captopril 25 mg po three times a day
  • Metoprolol 100 mg every day
  • Furosemide 40 mg po twice per day
  • Lipitor 50 mg once daily
  • Pilocarpine eye drops 2 drops each eye 4 times a day - Celebrex 200 mg po once a day
  • Tramadol 50 mg po every 4-6 hours prn pain

7) Ciprofloxacin 200 mg IV q 12 hours
8) Acetaminophen 325mg q 4-6 hours prn pain or fever
9) Labs: Send urine for C&S if not done in ED, repeat CBC, UA, CMP daily
10) PT and OT evaluation and treatment 


Dr. Eric Lund

Discharge Note

Name: Millie Larsen

S: Ms. Larsen has improved steadily in hospital x 2 days. No further confusion, less incontinence, no fever, eating well and ambulating well. She has no complaints today and is looking forward to return home

O: BP: 130/80, P. 64 and regular, R. 12 and unlabored

Eyes: PERRLA, fundi without AV nicking or exudates, no obvious papilledema
Ears: EACs clear and atraumatic, TMs pearly grey and translucent, hearing grossly intact to voice and whisper
Nose: nares patent bilaterally, septum intact, no discharge, polyps or bleeding
Mouth: Edentulous with upper and lower dentures which were damaged during her hospital stay during a near fall, gums and tongue show small cuts and some erythema, oral mucosa somewhat dry, pharyx non-erythematous without exudate, uvula midline
Neck: supple, full and nontender ROM, no bruits, no lymphadenopathy, no thyromegaly
Lungs: clear to auscultation bilaterally, no abnormal lung sounds
Heart: rate and rhythm regular, no murmurs, rubs or gallos
Abdomen: Soft and nontender, well-healed surgical scar upper right quadrant, bowel sounds normoactive, no hepatosplenomegaly
GU: deferred
BACK: Full ROM, no spinal tenderness, no CVA tenderness
EXTS: upper and lower extremities with grossly full ROM. No joint swelling, pulses 4+ and equal bilaterally. No calf tenderness. Both knees painful with ROM with mild crepitus.

LABS from Today:

  • Color: yellow and clear
  • Specific gravity: 1.015 (normal 1.005-1.035)
  • ph 6.0 (normal 4.5-8.0)
  • Pro: neg
  • Urobili: 1.0
  • Nit: Neg
  • Leu: Neg
  • Urine Micro:
  • RBC - 0 (normal 0-2)
  • WBC – 1 (normal 0-5)

Basic Metabolic Panel:

  • Na – 148 mmol/L
  • K - 3.7 mmol/L
  • Glucose  - 98 mg/dL
  • CBC
  • Hgb: 9.9 mmol/L
  • Hematocrit: 32 %
  • MCV: 72 fL
  • MCHC: 29 g/dL
  • WBC 12,000 


  1. Acute confusional episode- resolved
  2. Mild dehydration- resolved
  3. Urinary tract infection- resolved
  4. Hypertension- controlled
  5. Postmenopausal
  6. Osteoarthritis
  7. Stress incontinence- improving
  8. Glaucoma

1. Discharge home today
2. Home health to follow
3. Regular, low-fat diet
4. Continue home meds:

  • Captopril 25 mg po three times a day
  • Metoprolol 100 mg every day
  • Furosemide 40 mg po twice per day
  • Lipitor 50 mg once daily
  • Pilocarpine eye drops 2 drops each eye 4 times a day
  • Celebrex 200 mg po once a day
  • Tramadol 50 mg po every 4-6 hours prn pain

5. Follow-up with PCP in one week


Dr. Eric Lund


Occupational Therapist

Occupational Therapy Evaluation - Hospital Day 2

S:  Pt states she is unclear why she is hospitalized but guesses that her daughter, Dina “probably got worried again about me”.    She added that she thinks her daughter is “sort of paranoid about health related stuff ever since her husband Stephen died 6 years ago from brain cancer.” 

O:    OTR received orders to evaluate and tx.  Review of the chart reveals pt was admitted  via the ER for confusion after being found still in her bathrobe by the dgtr at 5pm yesterday.  Pt has hx of headaches, HTN since 2000, glaucoma since 2005, osteoarthritis of knees bilateral, stress incontinence, knee pain, and occasional urinary incontinence.   Pt was unfamiliar with OT and so she was provided with basic information about that as she initially claimed she had already been seen by a therapist earlier today.  OTR evaluated pt using unstructured interview,  the Activity Card Sort and the MOCA.  Kohlman was attempted but not completed.    Pt lives alone in a one story patio home in Sun City with cat, “snuggles” since spouse died aprox 1 yr ago.  Pt has 1 dgtr, Dina who lives in Queen Creek.    Pt states the following things are what matter to her the most at this stage in life:  gardening her prize roses, being able to cook for herself as she has heard that meals on wheels are terrible, attending church and being able to contribute to the committee that helps organize pot lucks and home visitations after members experience the death of loved ones, being able to use the computer in order to stay in contact with friends,  and seeing the grandkids, which she states is upsetting as they are becoming teenagers and are more into their own activities.  Millie states she believes the kids are avoiding her more lately and she overheard one of them comment to their mom about how her place “smelled like pee.” 

MOCA,  Score 25 out of 30 with most errors occurring in delayed recall and pt reported the incorrect date and day of the week.  Further evaluation recommended for mild cognitive impairment.  Pt said she does not feel she is as sharp as she was 1-2 yrs ago and also c/o feeling very sleepy at times. 

Kohlman, results incomplete but indicate some potential prbs with ADL and IADL function that warrant further eval that would be best done in pts own home.  (See below)

Activity Card Sort, Reveals decline in engagement in a number of IADLs including cooking dinner, paying the bills, and taking care of the yard.  She has increased participation in Low Demand Leisure such as playing the piano, photography and Bible Study, but is doing less recreational shopping, singing in the church choir, and attending concerts.  She explains the change as being related to her knees “which act up from time to time.  She admits she has dropped out of her previous walking club and no longer attends Tai Chi or the dances she once enjoyed.  Pt became tearful talking about the dances and admitted that it has more to do with the lack of a partner now that spouse has died than her knee pain.  Pt admits that she has used knee pain as a reason for not doing much lately because when she attempts to talk about the loss of her spouse, her daughter becomes upset.   Pt rates pain in knees as a 6 today and denies pain elsewhere.  She says she takes Ultram for the pain with some relief but adds, “it really makes me sleepy when I do”.    In the social realm, pt states she feels a bit lost without her husband as he always did the driving and they went everywhere together.  She feels frustrated that they had prepaid for a cruise to the Bahamas that they were never able to take. 

Evaluation with the Kohlman was not finished completely.  OTR used SBA as pt arose from bed.  She stated she needed to use the bathroom and moved quickly to get around the tray table but bumped the table hard with her forearm which caused her hearing aids,  glasses and dentures to crash to the floor and break.  Once in the BR she fumbled to get her underwear down and was slightly incontinent of urine on the floor, but seemed oblivious to that and the safety risk it presented when she got back up.  Urine was dark and foul smelling but pt flushed before nursing could witness.  Dark bruising was noted on both knees, which pt attributes to doing lots of weeding on her knees last week. 

A:  The following problems will be addressed by OT:

  1. Decreased engagement in usual ADL/ IADL, etiology uncertain, but likely due to some combination of physical pain and grief/loss/depression, and unexplained sleepiness
  2. Low endurance for ADL
  3. Safety risk during ADL with at least 1 near fall.  Requires contact guard to min A with gait belt for safety.


  1. Pt will identify at least 1 ADL/IADL activity in which she would like to increase engagement
  2. Pt will sustain dressing, bathing, cooking or other ADL at least 20 mins at least 2x a day by time of DC.
  3. Pt will be free of falls during dressing, showering, grooming, toileting while hospitalized. 


  1. OTR will use activity card sort to identify potential areas of occupational engagement for post DC
  2. Provide instruction in energy conservation, work simplification to improve tolerance for ADL
  3. OTR will instruct pt in adaptive ADL to help pt predict and plan for potential safety hazards during ADL.  Will use gait belt. 

DC Plan:  DC to self care at home with some support services to be determined in aprox 1 wk.  Pt would benefit from home health/safety  eval in her own setting.  Pt gives permission to talk to dgtr.

Pt called dgtr and reported the broken glasses and dentures before OT ended eval, but when she got off the phone she said, “OH BOY!  There she goes again.  She thinks I am expecting her to fly over here right now to do something about it, even though I told her it was no rush.  Jessica has a performance at school tonight and she will feel torn…..that is why I don’t tell her everything that is going on.  

Olivia Opres, OTR/L

Treatment Note - Hospital Day 3

S:  Pt c/o feeling “washed out”.

O:  OTR began ADL tx and safety tx today with emphasis on showering and dressing as pt states that is important today because the grandkids might be able to come visit tonight.  OTR provided CGA to MIN A and gait belt during transfer into shower with grab bars available.  Pt claimed she felt strong enough to tolerate a shower and declined offer of a bath chair for safety.  OTR instructed pt in the use of a draw sheet on her bed at home to prevent need for a full linen change at home if she should become incontinent.  

A:  Pt tolerated 10 mins in shower, requested help to wash her hair and her back and admitted she was very tired and wished she would have used the bath chair.  Pt states the physical therapist has been teaching her some things to do to prevent urine leakage and she is hoping she will be successful because she is afraid that she and her belongings have developed the stench of old urine and she is hoping she can prevent that.  Pt was I but slow, SOB,  and fatigued with UE dressing.  She requested help with shoes and socks and stated that she realizes now how rarely she wears anything other than flip flops lately.  Pt c/o of feeling embarrassed about her appearance without dentures, and now is not so sure she wants the grandkids to come visit. 

P:  Continue with original plan.  Attempt to contact Dina by phone again.  Unsuccessful in reaching her so far.  

Olivia Opres, OTR/L

Treatment Note - Hospital Day 4

S:  “some people say I will be discharged today, but I will believe it when I see it.”  Pt states she does not feel ready to be home alone yet but is unable to be specific re her reasons for this.

O:  OTR  continued ADL and safety training today.  Pt was willing  to accept use of bath chair, and held shower and long handle scrub sponge today.  Pt was more steady on her feet and required only CGA and gait belt for safety.  OTR recommends pt obtain the same equipment for home use, but the specific type of bath chair would be best determined by home health OT.  Pt says there is also a wellness program at her church that might be able to loan her some of the equipment if she wants.  

A:  Pt tolerated 20 min shower while seated with no hands on assist from OTR/L.  She denies any increase in pain and was not SOB.  Pt tolerated UE and LE dressing while seated in a chair at bedside.  There have been no falls or near falls during ADL reported by pt or nursing.  Urine is straw colored and not foul smelling now.  Pt believes she is making some progress in avoiding leaking.  Pt can state the correct date today and recall 4 out of 5 objects after 10 min delay.  

P:  Pt would benefit from continued OT in order to build ability to tolerate ADL without safety risk.  If discharged, pt would benefit from home health eval and safety recommendations.  Daughter still has not returned OTs phone calls.  OTR will contact MSW to recommend home health upon DC.  Request OT notes from hospital be sent with patient to home in order to improve continuity of care.  ​

Olivia Opres, OTR/L

Physical Therapy


S: When asked if patient has fallen in the past year, patient responded after much prompting “I might have fallen once or twice.” Patient also reports pain in both knees if she walks a lot.

O: History: Patient was admitted to the hospital via ED after her daughter found her to be very confused, including not remembering her daughter’s name. Lab work was positive for mild dehydration and UTI. Daughter is also concerned that the patient may be falling at home.

Social: Patient lives alone in a single story home. Patient’s spouse of 68 years died last year. Patient ambulates without an assistive device and is active in her church. Patient’s hobbies include gardening and cooking. Patient drives a golf cart short distances to/from grocery store. Patient has one pet (cat). Patient denies ever smoking, drinking alcohol, or using illicit drugs.

Cognition: A & O x 4. Patient follows directions throughout session. Sensation: Light touch sensation is intact bilateral UEs and Les.

Motor: AROM bilateral UE and LE: WNL. Strength: grossly 4-/5. Mild crepitus noted in bilateral knees. No swelling noted.

Integumentary: Faded bruising noted on bilateral knees. Balance: Patient completed Timed Up and Go Test in 22 seconds.

Mobility: Bed mobility: Independent. Sit to stand and stand to sit: Independent. Ambulated 75 feet with a slow gait pattern and decreased base of support without the use of an assistive device. No loss of balance when walking with increased time needed for changing directions. Patient tolerated sitting in chair x 45 minutes before becoming fatigued. 

Other: A small amount of urine noted on bed chucks. When asked, patient reports she has experienced loss of urine with coughing and laughing for the past year but has had some incontinence episodes with urgency over the past week. Patient reports she remembers having a strong urge to urinate while in bed but didn’t realize she had leaked urine. Patient asked if there is anything she can do to stop leaking urine.

A: Major impairments and activity limitations include:

Impaired balance.

Reduced gait speed

High risk for falls given past history of falls and TUG score of 22 seconds

Decreased endurance

Stress urinary incontinence x1 year and more recent episodes of incontinence not associated with stress, which may be due to UTI.


Ambulate 150 feet with no rest breaks.

Ambulate 100 feet while frequently changing directions and negotiating obstacles without loss of balance with or without assistive device (TBD).

Tolerate sitting in bedside chair for at least 1 hour.

Increased LE strength by 1/4grade to 4/5 for increased use in ADLs.

Completed Timed Up and Go Test in 14 seconds.

P: Therapeutic exercise and gait training QD-BID x 2-3 days. Progress sitting tolerance and distance walked. Gait training with focus on balance, especially with turns and negotiating obstacles. Patient and family education on reducing fall risks in the home. Will also assess whether patient would benefit from an assistive device. Discharge planning to include possible home health to decrease fall risk at home. Patient may also benefit from outpatient pelvic floor physical therapy to address urinary incontinence.

Marilyn Schwarz, PT, DPT 

Progress Note, Day 3 of hospital stay  

S: “I don’t want to use a cane or walker. I don’t fall that much and when I do, I always catch myself and don’t get hurt.” Patient reports she has not had any urinary incontinence episodes today.

O: Patient went from supine to sitting edge of bed independently. Patient educated on stress urinary incontinence and how strengthening the pelvic floor muscles can improve continence. Performed pelvic floor awareness exercises to help patient identify pelvic floor muscles. Patient instructed to contract these muscles before coughing and laughing (aka “The Knack”) to decrease leakage. Patient transitioned from sit to stand independently. Patient shown how to use a largel base quad cane. Patient initially reluctant to use cane; however once patient was told it may help her knees feel better, patient agreed to try using the cane. Patient ambulated 175 feet without using an assistive device and once using large base quad cane. No loss of balance noted either time. Patient ambulated faster with cane. Patient performed seated lower extremity strengthening exercises, including glut sets, quad sets, hip flexion, knee extension, and ankle pumps, 10x/set, 1 set each. After treatment, patient tolerated sitting up in chair for lunch x 60 minutes.

A: Patient did well with identifying pelvic floor muscles and contracting. Patient also ambulates with a faster gait using a large base quad cane, though patient reports she does not know whether she wants a cane for home.

P: Continue gait training, pelvic floor exercises, balance activities, and lower extremity strengthening exercises QD-BID. Will reassess assistive device needs.

Marilyn Schwarz, PT, DPT 

​Progress Note, Day 4 of hospital stay (Discharge Day)

S: Patient reports performing The Knack helps her leak less urine with coughing. Patient states she no longer leaks urine in bed, leakage now only happens with coughing and laughing. At beginning of session patient reported she does not want a cane to take home but by end of session patient agrees to using a large base quad cane.

O: Patient went from supine to sitting edge of bed independently. Patient educated on contracting the pelvic floor muscles slowly (hold 5 seconds) and quickly (hold 2 seconds) to strengthen the pelvic floor. Patient instructed to perform exercises while in bed and when sitting up in chair 10x/set, 3x/day. Patient transitioned from sit to stand independently. Gait training focused on higher level balance activities, including stepping over small objects, turning corners quickly, and walking backwards. Patient was unsteady and loss of balance x 1 with PT needed to prevent fall. Discussed fall risk and what happens when people fracture their hip. Patient performed same balance challenges with a large base quad cane and no loss of balance noted. Patient completed Timed Up and Go Test in 16 seconds without an assistive device. After treatment, patient tolerated sitting up in chair for lunch x 75 minutes.

A: Patient did well with identifying pelvic floor muscles and contracting. Patient would benefit from using a large base quad cane. Patient was much steadier when ambulating using the cane when her balance was challenged.

P: Recommend patient is discharged home with large base quad cane and home health PT to assess the home environment and mitigate fall risks. Once patient is discharged from home health physical therapy, if patient is still having urinary incontinence episodes, recommend patient to see outpatient pelvic floor physical therapist to address further treatment for urinary incontinence.

Marilyn Schwarz, PT, DPT

Speech and Language Pathology

Initial Evaluation: clinical examination of dysphagia

Patient Name: Millie Larsen
Reason For This Admission: confusion
Reason For Referral: OT noted chewing, choking, swallowing problems
PMH: HTN, hypercholesterolemia, glaucoma, osteoarthritis, stress incontinence

S: Patient was admitted after found in a confused state by the daughter who then brought her to the ER. Physician assessment revealed UTI, mild dehydration, and uncontrolled hypertension. Patient is now on antibiotics for UTI. Dehydration on admission is being treated with IV. Confusion is reportedly abating as hydration is improved. Dentures were broken while in her mouth during a fall. Upon admit she was placed on a regular, low-fat diet. OT noted difficulties swallowing as indicated above and patient was referred for swallowing evaluation and treatment as indicated.

Patient is at continued risk for falling. Today she is seen while sitting upright in a chair beside her bed, alert and oriented x3

O: Swallowing assessment was completed via administration of the Mann Assessment of Swallowing Ability (MASA) and food observations were completed at the same time with her lunch, using food from her tray supplemented by applesauce brought by clinician.

Inspection of the oral cavity revealed small cuts on the gums and tongue as well as erythema and edema of both gums and tongue. One spot of exudate was noted. Lip seal, tongue movement, and tongue strength were mildly reduced. Voice was clear. Laryngeal elevation appeared timely with full excursion as judged by finger palpation. Respiratory rate remained steady even while eating.

Functional implications were to the oral phase of deglutition where chewing was careful, slow, and labored and oral transit of bolus was slow. She avoided the hard, crunchy foods on her tray, eating only soft foods. One incident of coughing before pharyngeal swallow was noted, likely related to uncontrolled bolus during oral phase. Upon query the patient indicated that she preferred the applesauce that was provided, as it was easier to swallow and its cool temperature was soothing to her mouth. She indicated a willingness to eat a combination of very soft foods combined with ground meats while her mouth healed.

A: Total score on the MASA was 170, indicating possible dysphagia. Most signs and symptoms related to the oral phase and some alterations in function occurred in conjunction with facial grimace and verbalized discomfort while chewing and manipulating the bolus. While there are no clinical signs of aspiration at this time (temperature spikes, “wet” lung sounds) she was observed to cough once while eating.

P: Recommend that the Patient be placed on a modified diet with soft textured solids and ground meat to reduce pain associated with chewing and while awaiting mouth healing and new or repaired dentures. No liquid restrictions are needed.
Referral to ENT for assessment of redness and swelling in the oral cavity
Continue to monitor for changes in status of the oral cavity and swallowing function
Re-assess and if swallowing problems persist, videofluoroscopic swallowing study is recommended to delineate swallowing physiology.

Recommended swallow strategies to decrease painful episodes:

  1. Very soft foods with ground meats
  2. Eat slowly while sitting upright.
  3. Avoid salty and spicy foods and also foods of extreme temperatures (hot and cold)

Katherine Janeway, M.A., CCC/SLP


S: Patient is seen while sitting upright in her chair, alert and oriented. ENT report confirms presence of oral candidiasis, likely resulting from synergistic reaction to antibiotics, cuts in mouth from fall with denture breakage, and xerostomia. Treatment for candidiasis was initiated and the Patient reports that swallowing is less painful much of the time.

O: Re-assessed swallowing function with mechanical soft foods. Oral preparatory and oral transport phases was more timely and facial grimaces were absent, although she appeared to manipulate and swallow the food carefully. No incidences of coughing or choking were observed.

A: Swallowing function is improved. Per patient and nursing oral intake is improved. 

P: Recommendations:

  1. Continue mechanical soft diet
  2. Evaluated status in one-to-two days to monitor changes

​Katherine Janeway, M.A. CCC/SLP


S: ENT reports excellent response to treatment for candidiasis. Patient is seen while sitting upright in her chair, alert and oriented. She reports that mouth pain is nearly gone and it is easier to eat. Nursing reports that intake has continued to improve and duration of meal time is now shorter.

O: Re-assessed swallowing function with mechanical soft foods. Oral preparation and transport are both within functional limits. No signs of aspiration were observed.

A: Swallowing function is much improved. Per patient and nursing oral intake continues to improve.

P: Discharge Recommendations:

  1. Continue mechanical soft diet while awaiting denture repair/placement
  2. Re-assess only if swallowing problems persist after she acquires new dentures.

​Katherine Janeway, M.A. CCC/SLP 

Social Work


Patient Information
Millie Larson is an 84 year old Caucasian female. She lives alone in her home with her beloved cat, Snuggles, in Sun City and has been a widow for about 1 year. She is being referred to Social Services for assistance with discharge planning.

Financial Information
Mille has two sources of income; Social Security and a small pension from her husband’s employer. Her total monthly income is approximately $1400.00 per month. Millie has Medicare part A & B but does not have a medication benefit, nor does she have dental insurance. Despite having her home paid off, Mille struggles to meet her monthly expenses. She states that her medications are very costly and that with her home being older, her utility bill is high. Milles adds that she sometimes has to “skimp” on groceries in order to make ends meet. She notes that she will often eat Top Ramen for dinner or eat an inexpensive frozen meal.

Dental/Oral Health
Millie wears full dentures that have been damaged. When asked, Millie could not account for how and when they were damaged. She notes that she has difficulty eating as a result.

Physical Health
Millie is diagnosed with high blood pressure, glaucoma, osteoarthritis of the knee, stress incontinence, osteoporosis, and high cholesterol. When asked she reports that takes her medications as prescribed, using a medication cassette as a way to organize her regime. There is also repot of an episode of confusion which appears to be resolved, according to the medical notes. There also seems to be potential for balance issues as evidenced by a near fall on day 2 of her hospital stay. This fall resulted in damage to her hearing aid and glasses that will now need to be replaced. Millie denies any balance issues at home. 

Family/Social Support System 
Millie has one daughter, Dina, who is 50. Dina is also a widow of 6 years and is raising 3 children ages, 17, 14, and 12. They are very active teenagers and have limited ability to assist Millie in meeting her needs. Millie is also a very active member of her church and has a small group of friends that drive her to doctor appointments and aid in other small tasks. They have offered to do more, but Millie states “I prefer my daughter’s help.” 

As part of the interview, Dina discusses her own concerns about Millie’s ability to function at home independently. She notes the Millie does not take her medications as prescribed. Dina explains that during her weekly visit, she finds medications in the cassette that should have been taken days prior. She also adds that she is very suspicious that her mother is falling at home as Millie has minor bruises/injuries that Millie cannot explain. Dina reports that when she asks her mother about them, Millie states, “Oh I don’t know! I’m alright. Just give it a rest!” Dina continues to say the she loves her mother very much and cannot bear to lose her. She adds that between the demands of her job and her mother’s needs she is really at a loss. Further, the sorrow she feels at the loss of her father often leaves her feeling low and fragile. This is why, she states, she wants Millie to move in with her. “We still have each other, and I think we can make it work.” 

Upon hearing this, Millie states the moving in with Dina cannot work because she does not want to be a burden and is unwilling to give up her cat, Snuggles. Millie firmly states that she wants to go home and return to their same weekly visit schedule. “I’ll be alright, you’ll see. You worry too much, I’m fine.” 

In relation to transportation, Millie uses a golf cart to get around. This presents some concern to Dina as Millie experiences episodes of losing her balance and Dina worries that her mother may crash and hurt herself or another person. Millie asserts that she is fine and uses the golf cart for short trips. Dina confirms that she drives Millie to doctor’s appointments and other places when driving on main roads is necessary.

Psychosocial Assessment Summary

S/O - Millie is an 84 year old Caucasian female who lives alone in her home in Sun City. She is recently a widow approximately one year. She was admitted to the hospital for UTI, dehydration and confusion. She was referred to Social Services for assistance with discharge planning. Her daughter Dina reports that Millie is not functioning well at home i.e. not taking her medications the way they are prescribed, potentially falling at home, and has a very limited income. Millie denies any problems at home and asserts that she wants to go home. She adds that she is unwilling to give up her cat, Snuggles. 

- There is clear disagreement between Millie and her daughter Dina. Millie wants to return home and Dina wants Millie to move in with her. Millie appears to minimize her daughter’s concerns and does not want to be a burden. Dina is concerned that her mother’s health will decline and does not want to lose her. Nevertheless, Millie is her own agent and has the right to return home if she wishes. Millie’s income is restricted in that her prescription costs are high along with high utility bills. This will make affording new dentures, glasses, and a new hearing aid problematic. Millie’s home environment is not ideal, however, continuing to live alone should not be ruled out. Appropriate supports should be attempted before alternative more drastic plans such as moving are put into place. Both Millie and her daughter appear to be impacted greatly by the loss of Millie’s husband, Dina’s father. They appear to be able to function day to day, however, with great sadness and feelings of loss. Dina is Millie’s main source of support. Millie does have a group of friends from church that are willing to assist in a greater capacity. The relationship seems strained on the surface, but there is clearly a functional loving relationship between them. They both want what they think is best for the other. 

- Discharge Millie to her home with the support of home health services. It is advised to include a home health social worker to address the following: 


  1. Relational discord between Millie and her daughter Dina. 
  2. Needed supports to increase Millie’s independence in her own home. 
  3. Financial restrictions. 
  4. Replacement of dentures, glasses, and hearing aid. 
  5. Grief issues. 
  6. Expanding support system to relieve Dina of some of her duties. 
  7. Caregiver support information for Dina.

Gina Spadafino, MSW, LCSW 

Health Educator

Health Educator/Health Education Specialist NOTES and ASSESSMENTS

Profession Description :
The U.S. Department of Labor Bureau of Labor Statistics (BLS) defines health educators (SOC 21-1091.00) as those who promote, maintain, and improve individual and community health by assisting individuals and communities to adopt healthy behaviors, collect and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies and environments. They may also serve as a resource to assist individuals, other professionals, or the community, and may administer fiscal resources for health education programs.  

Health educators work to encourage healthy lifestyles and well­ness through educating individuals and communities about be­haviors that promote healthy living and prevent diseases and other health problems. 

Responsibilities and Competencies for Health Education Specialists 
Seven Areas of Responsibility: 
Area I: Assess Needs, Assets and Capacity for Health Education 
Area II: Plan Health Education 
Area III: Implement Health Education 
Area IV: Conduct Evaluation and Research Related to Health Education 
Area V: Administer and Manage Health Education 
Area VI: Serve as a Health Education Resource Person 
Area VII: Communicate and Advocate for Health and Health Education

Brief Video about Certified Health Education Specialists/Roles and Responsibilities: 

Brief Videos: What is Public Health/This is Public Health:

Certified Health Education Specialist (CHES) “Consult” - Health Education/Community and Public Health: FALL PREVENTION
Patient Education Information/Materials; Programs and Interventions    

“Health Educators plan and implement evidence-based programs/interventions, so I would recommend some resources….”

Each year, millions of adults aged 65 and older fall.1 Falls can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death. Fortunately, falls are a public health problem that is largely preventable.

  • One out of three older adults (those aged 65 or older) falls each year1 but less than half talk to their healthcare providers about it.2
  • Among older adults, falls are the leading cause of both fatal and nonfatal injuries.3
  • In 2013, 2.5 million nonfatal falls among older adults were treated in emergency departments and more than 734,000 of these patients were hospitalized.3
  • In 2013, the direct medical costs of falls, adjusted for inflation, were $34 billion.4
  • Twenty to thirty percent of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, and head traumas.5,6 These injuries can make it hard to get around or live independently, and increase the risk of early death.
  • Falls are the most common cause of traumatic brain injuries (TBI).5
  • About one-half of fatal falls among older adults are due to TBI.7
  • Most fractures among older adults are caused by falls.8 The most common are fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand.9
  • Many people who fall, even if they are not injured, develop a fear of falling.10 This fear may cause them to limit their activities, which leads to reduced mobility and loss of physical fitness, and in turn increases their actual risk of falling.11

PATIENT EDUCATION - STEADI Initiative for Health Care Providers

Falls are not an inevitable part of aging. There are specific things that you, as their health care provider, can do to reduce their chances of falling. STEADI’s tools and educational materials will help you to:

  • Identify patients at low, moderate, and high risk for a fall;
  • Identify modifiable risk factors; and
  • Offer effective interventions.

Other Assessment options 

Health Educators offer community-based/population-based fall prevention programs that you can refer patients to: ; ; ; 

We recommend following the Community Guide as a starting point to finding best-practice interventions  and programs in your community: or also: ;

Certified Health Education Specialist (CHES) “Consult” - Health Education/Community and Public Health: ARTHRITIS / OSTEOPOROSIS

“Health Educators plan and implement evidence-based programs/interventions, so I would recommend some resources….”

Although the word arthritis actually means joint inflammation, we use the term arthritis in the public health world to describe more than 100 rheumatic diseases and conditions that affect joints, the tissues which surround the joint and other connective tissue. The pattern, severity and location of symptoms can vary depending on the specific form of the disease. Typically, rheumatic conditions are characterized by pain and stiffness in and around one or more joints. The symptoms can develop gradually or suddenly. Certain rheumatic conditions can also involve the immune system and various internal organs of the body. Arthritis types: ; National Public Health Agenda: 

PATIENT EDUCATION – Your health educators teaches the following classes in the community: Arthritis Self-Management Program (ASMP), Chronic Disease Self-Management Program (CDSMP), Tomando Control de su Salud (Spanish Chronic Disease Self-Management Program), Programa de Manejo Personal de la Artritis  (Spanish Arthritis Self-Management Program — SASMP)

The CDC Arthritis Program recommends evidence-based programs that are proven to improve the quality of life of people with arthritis. The programs currently being recommended are –

We recommend following the Community Guide as a starting point to finding best-practice interventions  and programs in your community: ; A compendium of CDC Arthritis Program recommended evidence-based intervention programs is now available. The purpose of this compendium is to assist you in selecting interventions by providing a concise, standardized review of each intervention. Compendium of Arthritis Appropriate Physical Activity and Self-Management Education Interventions :

Certified Health Education Specialist (CHES) “Consult” - Health Education/Community and Public Health

“As a health care professional, you assess patients all the time. But you generally do not assess a patient’s family caregiver, except to identify that person as a “resource” or “informal support” when developing a discharge plan. In this traditional view, the family caregiver, who is not a client or a beneficiary and not an official part of the health care team, is typically outside the realm of professional responsibility. Like so much of health care today, that view is changing. Increasingly professionals “hand off” very sick or disabled patients to family caregivers after a hospital stay, a short-term nursing home stay, or an episode of home care services. In these transitions, especially when the patient is elderly or chronically ill, the patients’ continued health and well-being depends on a family caregiver. That person must be willing and able to handle the patient’s complex health, financial, legal, and social needs. Sometimes these tasks are temporary, while the patient recovers; in the case of elderly or seriously ill patients, the job can continue for months or years. 

Caregiver assessment is a tool to help identify strengths and limitations to help develop a realistic plan for the next stage of care. The goal is twofold: (1) to ensure that the patient’s health and well-being are maintained and enhanced; and (2) to ensure that the caregiver’s capacities and needs are considered and addressed in a care plan.”

Health Educators conduct “assessments”; so….

“I would recommend…” …A Caregiver’s Assessment: ask Dina about…

  • The caregiver’s background, including age, education, employment, other family responsibilities, living arrangements.
  • The caregiver’s perception of the care recipient’s health and functional status.
  • Length of time the caregiver has been providing care; if is a new event, what the caregiver worries most about in providing care.
  • Values and preferences about caregiving (“do it all myself,”; “can’t deal with needles or incontinence,”; “I can’t take Mom to my home because there just isn’t room for another person”).
  • Caregiver’s health status, including any limitations relevant to caregiving.
  • Impact of caregiving on emotional status, finances, other family members.
  • Knowledge, skills, and abilities to perform necessary caregiving tasks.
  • Resources used or interested in accessing.

In introducing the assessment process to the family caregiver, the assessor should clarify the goals of the assessment and make it clear that all information (unless specified by the caregiver) will be shared with the health care team in order to develop a care plan. The assessor should also summarize the  conversation, so that the family caregiver feels that his or her concerns have been heard. The assessor can emphasize the positives first, and then list the areas where some questions have been raised, and suggest a process for following up.

Another option/tool:  Caregiver Self-Assessment  

Certified Health Education Specialist (CHES) “Consult” - Health Education/Community and Public Health


“We ALSO recommend some Patient and Family Education for Transition; Elder advocacy resources, good discharge planning that meets the needs of all…and we advocate for SAFE transitions…”

Home and community-based care providers: 
AZ Department of Health : 
Home health compare: 
Alternatives to nursing homes:…
Understanding discharge planning for patients/caregivers:
Fact sheet on safe transitions:…
Post discharge tool for patients:…
Resource: toolkit for healthcare providers: