Thirty

Thirty-nine-year-old (DOB: 01/09/60) D.H. is a Caucasian male who was a pedestrian, struck by a motor vehicle on 03/20/97, resulting in a traumatic head injury. He was transported to University Medical Center where he presented positive for a loss of consciousness and was assessed with a Glasgow Coma Scale of 5. He was intubated, placed on a mechanical ventilator and admitted to the surgical intensive care unit. Head computerized tomography illustrated a right temporal lobe contusion, open cisterns "possible subarachnoid hemorrhage versus a brain stem contusion on the right." There was no midline shift. His head injury was consistent with a diffuse axonal injury and a temporal lobe contusion. Moreover, he was found to have a "right Monteggia fracture and right olecranon fracture." On 03/27/97, he had orthopedic surgery for his Menteggia fracture and underwent closed reduction of the radial head and open reduction and internal fixation of the right olecranon. On 04/01/97, he was operated on for a jugular Greenfield filter placement, jejunostomy feeding tube , gastrostomy tube and tracheostomy. By 04/09/97, he was neurologically stable with a Glasgow Coma Scale of 9.

D.H. was, on 04/28/97, admitted to Columbia West Florida Rehabilitation Institute where he was treated until his discharge on 06/06/97. While at the institute a psychological evaluation demonstrated positive for depression, hence he was placed on Zoloft 50 milligrams, by mouth on 05/16/97. During his stay he started to reveal increasing violent content in his language and his ideations were delusional and confabulatory as he explained that he was being monitored by the FBI. His hospital course was remarkable for stabilization of his seizure disorder and somnolence. Based on the medical records from University Medical Center and Columbia West Florida Rehabilitation Institute he is appropriate for a 60-90 day neurobehavioral restoration evaluation and treatment course at FINR. From the medical department, both the neurologist and neuropsychiatrist will evaluate, treat and chart Mr. H's progress during his stay.

The neuropsychologist will perform standardized testing to ascertain brain behavior impairment and produce treatment recommendations. He will be assessed by all other multidisciplinary treatment team members to potentiate his recovery, including speech and language pathology, physical and occupational therapies. The department of vocational rehabilitation will develop a program aimed at actualizing his abilities for future employment. The nurse liaison will correspond with the necessary facilities for pertinent records. The department of nursing will educate Mr. H regarding his medication use and dosage.

Health. Currently D.H. is treated with Zoloft 50 mgs, Depakote 500 mgs BID, and Hydroxye 25 mgs at bedtime. He has been seizure free for one year while on Depakote. He has complete control over his bladder and bowel management. He is able to chew and swallow without risk of choking. His hearing and vision are within normal limits and he does not use glasses or aids.
Personal and self-care. He is independent for grooming, feeding, toileting, dressing and hygiene care. He has difficulty sleeping at night, in part due to his fear of being attacked. He believes he has to "patrol the house to keep my family safe."
Physical functioning and mobility. D.H. has adequate motoric abilities for ambulating and transferring and he does not use adaptive equipment. Despite his right arm fracture he has adequate range of motion, strength and coordination. He ambulates with a rigid gate. Physical therapy will need to evaluate him and develop a program if necessary for his right arm which was fractured and for his stiff and rigid gate and balance difficulty.
Cognitive skills. D.H. will have, while at FINR, a standardized neurocognitive evaluation to ascertain brain behavior relationships. His abilities for abstract reasoning, concept formation, complex problem solving and cognitive flexibility are compromised, yet the degree of impairment will need a formal assessment. He has mild to moderate difficulty making reasonably safe decisions regarding his finances, social and personal issues. He is not only alert, rather he is vigilant and manifests a dual diagnosis of psychiatric disorder secondary to brain injury. He is unable to sit and concentrate to learn in an academic setting. Nevertheless, he would be able to achieve skill building in an on the job situation while placed in vocational rehabilitation. His memory, which will be assessed is moderately impaired for the retention and retrieval of visual and auditory information. He is oriented to persona and place but needs reminding of the date. He has an 11th grade education and matriculated at a vocational institution for welding.
Community integration. D.H. does not initiate recreation nor entertainment. He is disinterested in social activities and will need to be included in group activities and reinforced for his social participation. He is able to carry petty cash for entertainment and snacks but not for a major purchase. With supervision he can prepare snacks and simple meals and clean-up. He can perform his laundry and household chores under supervision. He can identify household hazards and dangerous situations but it remains questionable whether he could access emergency services during a crisis. Occupational therapy will evaluate him for a program to prepare him for independent supervised living.
Communication. D.H. has adequate cognitive ability to follow simple commands and comprehend casual conversations and express his thoughts and needs. His ability to read is diminished and he can write some single thoughts. His speech is animated, replete with affect and he swears a lot. Speech and language pathology will evaluate him for a program to improve his skills related to reading and writing and more complex auditory comprehension tasks.
Behavioral adjustment. D.H. presents hypermanic and unable to sit still. He is paranoid of others attempting to harm him and his family. His restlessness and agitation results in verbal abuse or reclusiveness. He denies suicidal ideation and depressed feelings and thoughts. Although he denies both hallucinations and delusions there is documentation of paranoid ideations . He is easily frustrated, he cannot delay gratification and does not accept when limits are set for him. Treatment staff will reinforce his engaging in activities that are incompatible with aggression, agitation and restlessness. He will be rewarded for participating in relaxing activities. The neuropsychiatrist will evaluate him for pharmacological intervention regarding his paranoid delusions. He will be included in group therapy and referred for individual if necessary.
Psychosocial. D.H. will be rewarded for participating in social activities, for discussing his paranoid ideations and accepting feedback from treatment staff. He is unaware of the extent of his verbal abuse, agressiveness and ideations, therefore treatment staff will educate him as to how his neuropsychological injury produces paranoid ideations and hypervigilance.
Discharge. He will return home or to an independent supervised living arrangement. His family will be included in family education sessions at FINR to further enhance their stress management, and ability to assist the patient in generalization of skills once discharged.