Fifty-two-year-old (DOB: 12/26/46) V.D. is a Caucasian male who has been medically followed by Southeast Alabama Medical Center for his depression with dementia secondary to a traumatic head injury. He is two years status post traumatic head injury, which occurred in November 1997, when he fell approximately 20 feet from a scaffold while employed as an ironworker. Germane to his head injury he sustained a right temporal-parietal epidural hematoma with mass effect, left parietal-frontal subdural hematoma and right temporal bone fracture. Additionally, he suffered a fractured clavicle, multiple rib fractures on the right side and right hemothorax. He was transported and treated at East Alabama Medical Center in Opalika, Alabama. Later, he was transferred to HealthSouth Inpatient Rehabilitation Hospital of Dothan, Alabama on 12/10/97. He was admitted on October 5, 1998 to FINR for a brief 30-day stay on October 5, 1998.

Results of his first admission were as follows: The client became independent in all ADL's and ambulation. He made significant strides in problem-solving abilities and his level of insight into his problems. However the patient's lack of motivation to follow-through with the recommendations made by FINR caused a relapse in his level of functioning and ability to deal with his frustrations. This created a need to become overly dependent on medication.

In May 1999, Mr. D. was admitted to Southeast Alabama Medical Center for stabilization of his depressive illness secondary to his head injury (dementia). During this hospitalization he was described as depressed, expressing helpless-hopeless ideations, unable to concentrate, anxious and voicing suicidal thoughts and was crying and unable to sleep. He was admitted again on 07/15/99 manifesting the same symptoms and was diagnosed with 290.1 dementia with increasing depression secondary to head injury and chronic headaches, vertigo with tinnitus. He had been medicated with Paxil, Risperdal, Eskalith, Profene, Dilacor, Trazodone and Antivert.

Dr. Michael Passler, Psychologist, has been treating Mr. D. since 10/27/98 and has documented his progress related to his depression. From the progress notes it seems his recovery is very slow and at times characterized by regression.

Mr. D., is clinically appropriate for a 60-90 day neurobehavioral evaluation and treatment at FINR. His entry level status in regard to his neurologic and behavior presentation will be ascertained during admission, and there will be immediate intervention of treatment, including cognitive, behavioral and physical therapy. While at FINR he will be evaluated by the neurologist and neuropsychiatrist for a treatment plan and will be followed throughout his stay.

It is recommended that during this admission, the patient, be placed on a medication holiday and work on his ability to manage his frustrations and intolerances without pharmacological intervention. He must learn to de-escalate during periods of anger and frustration and accept construction criticism and feedback. Overall the client demonstrates much more motivation to begin adjusting to his disability and the lifestyle changes that have resulted. The neuropsychologist will perform neuropsychological testing and develop recommendations for compensatory restoration. He will be assessed by all members of the treatment team for a treatment plan. The department of vocational rehabilitation will assess his skills, proclivity and affinity for future job placement. He will be placed in a skill acquisition program in aim of potentiating his skills for placement after discharge. The nurse liaison will correspond with necessary medical facilities for pertinent records.

• Health. Mr. D. is a well-nourished male on a regular diet and without seizures. He is prescribed Celexa, Desyrel, Ambien, Saraguel, Neurotin, Celebrex and Aspirin. Our Physicians will perform a careful assessment of the patient's need for all medications and adjust accordingly The possibility of a medication holiday will be taken into consideration based on the results of this analysis. He wears eyeglasses, mostly for reading and dentures. He has, during daytime hours, full management of his bowel and bladder functions, yet at night has mild problems with bladder control and will need a bladder program. He complains of dizziness, ringing in the ear and most of all severe depression.

• Personal and self-care. Mr. D. will need several prompts to wake him from his night's sleep, especially considering it may take him hours to overcome his restlessness before falling asleep. He is independent for feeding, grooming, hygiene and dressing. He might have an occasional enuretic episode at night requiring a shower in the morning.

• Physical functioning and mobility. He currently presents within normal limits for physical functioning and mobility. His strength, endurance, and coordination appear unimpaired, yet his daily activity schedule reflects a significant decrease juxtapose his pre-morbid level of functioning. Physical therapy will ascertain his entry-level status and determine, if clinical intervention is necessary to improve performance. He will need an exercise maintenance regime to recover his loss.

• Cognitive skills. Mr. D. has limited insight into his cognitive deficits. He is unable to produce abstract reasoning, concept formation and complex problem solving. His proclivity for planning changing mental sets and sequencing is impoverished. He is unable to reasonably make safe and gainful decisions related to social, personal and financial matters. His memory, without formal standardized testing, is moderately compromised. He will need a neuropsychological assessment of his cognitive abilities for vocational rehabilitation placement and future guidance. He will, while at FINR, have an assessment with the vocational rehabilitation department for job placement and skill acquisition.He is alert, able to concentrate briefly for learning and retraining. He verbalizes a desire for vocational rehabilitation.

• Community integration. Mr. D. currently is too withdrawn to spontaneously initiate social interaction and entertainment. Nevertheless, he will participate in structured activities and programs with supervision. He is unable to handle money for significant or major purchases, but can handle money for purchasing food, snacks and personal items.Mr. D. is able to manage preparing simple meals, laundry and household cleaning. He is able to recognize household hazards and access emergency services using the telephone. Occupational therapy will assess his skills for daily functioning and develop a program to compensate for his deficit.

• Communication. Mr. D. is adequately able to comprehend simple conversations, communicate his needs and ask questions. In general, he can carry a social conversation despite his work finding difficulty and topic digression. His speech is mildly tangential or circumstantial, but he can be redirected easily. He is able to read and write at a decreased level. Speech and language pathology will make an assessment and ascertain the need for clinical intervention.

• Behavioral adjustment. Mr. D. is languid, depressed and frustrated over his impairments and depending on his wife financially for day-to-day problem solving issues. Although he has never verbalized a suicide plan, he has stated that he wished he would die. He is withdrawn and lacks creativity and spontaneity for social and leisure activities. He will be included in group psychotherapy and individual therapy if deemed appropriate and necessary. He is usually never argumentative, whining nor combative.

• Psychosocial. Mr. D. is dauntful of going out in public places where he will not recognize others who greet him as friend. Oddly, he denies the severity of his neurocognitive deficits yet is severely depressed over his current level of dysfunction. He is depressed, focuses on inability to work, not being an adequate father to his son or adequate husband to his wife. He has decrease desire and energy for intimacy. Treatment staff at FINR will reinforce methods for expressing himself. This will include the reinforcing and modeling of frustration tolerance, accepting limits, controlling agitation and anger. He will be rewarded for goal acquisition and spontaneous social interaction.

• Discharge. Mr. D. will return home to family once goal accomplishments have been achieved. His family will be included in family education sessions at FINR to continue with behavior strategies for stress inoculation and preventative treatment. He will be discharged home and wraparound services will be provided by a, Rehabilitation Counselor, of the Easter Seals to provide vocational and avocational training.