Thirty

Thirty-four-year-old (DOB: 11-06-64) J.F.. sustained on, 03/26/95, a traumatic brain injury secondary to an accident whereby he was struck by a motor vehicle while walking. He was transported to Halifax Medical Center in Daytona, Florida where CT scans illustrated parenchymal contusions and a right temporal and a left anterior temporal skull fracture. Specifically there was evidence of a right epidural and subdural hematomas and contusions bifrontally with extra-axial blood over the right hemisphere. He was reportedly comatose for approximately two months. His C-2 vertebrae fracture was not diagnosed upon admission, instead due to the sequella of neck pain a second cervical spine MRI identified the Type II odontoid fracture. On 07/18/95, he returned for a C1-2 trans-articular screw fixation and fusion with iliac crest allograft. The department of radiology at Halifax Medical Center, later on 07/14/95 and 07/17/95, found evidence through a CT scan of encephalomalacia and lacunar infarct of the right thalamus and part of the hypothalamus were unchanged. Mr. F.'s neurocognitive restoration and rehabilitation had a protracted course. He attended rehabilitation at a host of facilities including CRAFSS in 03/17/96 with a readmission on 09/09/98, Charter Hospital, Seminole, FL, Bayfront Medical Center (Brain Injury Unit), St. Petersburg, FL, Neurobehavioral Resources, Conroe, TX and Tangram, San Marco, TX. His most recent admission was to Brown School Rehabilitation Center on April 8, 1999. His behavior is described as suspicious of others stealing from him, he is provocative, easily distracted, and denies his neurocognitive deficits. With consideration to Mr. F.'s medical records, he is deemed appropriate for a 60-90 day neurobehavioral assessment and continued restoration course at FINR. He is referred by Caren Zysk, External Case Manager wit Consentra. Evaluations by FINR's neurologist and neuropsychiatrist will be performed along with following Mr. F's progress during his stay. The neuropsychologist will perform neurocognitive tests to assess his current level of functioning and make treatment recommendations. Mr. F. will be evaluated by speech and language pathology, physical and occupational therapy for a program to actualize his abilities and prevent relapse. He will be evaluated by vocational rehabilitation to develop skills for future possibilities. He will have a behavioral protocol to decrease his inappropriate disinhibited behavior and to increase his interests and participation in appropriate activities and programs. The department of nursing will include him in educational classes for understanding the use of his medications. Nursing will also liaise with the facilities that treated Mr. F for necessary records.

Health. Mr. F. has full management over his bladder and bowel functions. He is able to chew and swallow without risk to choking. His hearing and vision are unimpaired nevertheless he wears eye glasses for reading. He had surgery for a C1-C2 fusion and screw fixation in 1995.
Personal and self-care. Mr. F. is capable of feeding without adaptive utensils, grooming, bathing, dressing and toileting independently. With supervision he is able to maintain adequate hygiene and physical appearance.
Physical functioning and mobility. Mr. F. ambulates with a limp resulting from missing two toes on his left foot. He continues to complain of chronic shoulder and back pain. The neurologist evaluation will include an examination of his back and shoulder. The physical therapist will assess whether this chronic condition is treatable and determine which behaviors exacerbate the condition and which compensatory behavior may be needed to avoid the reoccurrence. He ambulates without adaptive equipment and is able to climb stairs and inclines and manipulate transfers while showering and toileting.
Cognitive skills. A June 1999, neuropsychological evaluation was performed on Mr. F., while at the Brown School Rehabilitation Center. He achieved a full scale IQ of 80, placing him in the low average range with an IQ of 94 in the verbal section and in the performance section his IQ of 67 placed him in the impaired range. His memory for verbal information was average to low average but for visual memory was mildly impaired.His performance was moderately to severely impaired on visual scanning, sequencing and for concept formation; abstract reasoning and incidental memory results were within the low average range.Objective testing demonstrates serious psychopathology including confusion, derealization, with bizarre ideations. He is self-centered, infantile, emotionally labile and feels inferior and inadequate.The need for further testing will be determined by the neuropsychologist. He is unable to make safe and reasonable decisions related to financial, social and personal matters, without supervision. He is alert and able to attend adequately to relearn.
Community integration. Mr. F. is able to engage in recreational activities and can entertain himself when done for short periods. He is able to plan and prepare simple meals and clean-up after dinner with supervision. He needs supervision to organize household cleaning and maintenance. He can recognize household hazards and access emergency services with supervision. Occupational therapy will construct a program to improve his skills for supervised independent living.
Behavioral adjustment/psychosocial. Mr. F. is sexually inappropriate when he is around females. He inappropriately agitates other peers and uses his large size to intimidate others. Once he is angry he is difficult to redirect and reason in verbal conversation. He denies having any impairment and lacks insight into his neurocognitive condition. He has poor tolerance for frustration and will become verbally aggressive if not combative. Usually he complains and argues to manipulate others. Mr. F.'s behavioral protocol will direct efforts towards increasing appropriate social interaction, reducing inappropriate sexual behaviors, and aggressive manipulation of others. Mr. F. lacks insight into his brain-behavior impairment. Treatment staff will discuss his deficits as it manifests and reward him for accepting his condition and for acquiring awareness and insight.
Treatment Progress- JF continues to work toward a trial home visit at Christmas and increased awareness of his disabilities. The client is currently involved in both the vocational and neurobehavioral program at FINR. He is beginning to attend to tasks in the woodshop with less need for redirection. However in large community outings in a group, the client needs one on one support and redirection of behaviors. JF has improved in his ability to keep behaviors in check during dinner outings with his father which is a marked improvement. The family is very supportive and regularly visits and works with JF on generalization of appropriate behaviors outside of the FINR campus.
Discharge. He will be transferred to a supervised independent living arrangement at FINR once he has achieved compensatory skills and a greater degree of behavioral inhibition.