Sixteen-year-old J. H.  is a  white female who was involved in a motor vehicle accident on December 6, 1998.  Reports describe an impact whereby she struck her head on the windshield of the car rendering her unconscious.  At the scene her Glasgow Coma Scale was 3. She was intubated and transported by helicopter to Memorial Regional Hospital in Hollywood, Florida. She was admitted and taken to the intensive care unit due to her intracranial hemorrhage which 24 hours later resulted in evacuation.  She was placed on a ventilator and a tracheostomy was performed.J.H.'s  preoperative diagnosis was left frontal hemorrhagic contusion and multiple skull fracture.  She had a left frontal craniotomy with evacuation of the intracerebral hematoma .  The dural tear and skull fracture was repaired.  Additionally she suffered lacerations to the liver, face, left eyelid, and a right femur fracture.On January 20, 1999 she was transferred to Moss Rehab Hospital in Philadelphia, Penn.  The February 17, 1999, Moss Rehab Hospital's assessment using the CT of the head revealed bifrontal contusions evolving into bifrontal atrophy with decreased enhancement and with hydrocephalus "present and stable".J.H. was transferred to Healthsouth, Sunrise Rehabilitation Hospital on April 13, 1999.  At the time her mental status had improved.  She was more alert and oriented to person and could identify significant relationships.  She was labile as she cried easily and yelled obscenities without provocation.  She was able to count but had difficulty identifying objects.  She could follow three step commands.

While at Healthsouth her outbursts decreased but she still had difficulty focusing and required redirecting.  She remained uncooperative and easily frustrated.

As per the records from Memorial Regional Hospital, Hollywood, FL, Moss Rehab Hospital, Philadelphia, PA, and Healthsouth, Sunrise, FL, she is appropriate for a comprehensive 30-60 day intensive evaluation and treatment of her post acute head injury.  FINR neurologist and neuropsychiatrist will assess her for neurocognitive restoration.  The neuropsychologist will test her for higher cortical dysfunction and offer treatment recommendations.  The physical therapist will evaluate and design treatment for full recovery of her fractured leg.  Occupational therapy will design a program to reinstate her skills of daily living.  The speech and language pathology will develop a program for speech recovery including her dysnomia.  The nurse liaison will correspond with the pertinent hospitals for treatment records.  She will need an ophthalmologist to render treatment for her eye due to contagiousness of the infection.

• Health.  J.H  has a G-tube for supplemental nutrition.  She is 5'4" and weighs 98 pounds.  She has moderate problems with both her bladder and bowel management.  She needs to feed herself with small bites and she is on a regular diet.  Her hearing is adequate but has problems with her vision, she sees black in her left eye and wore glasses before the accident.

• Personal and self-care.  She needs to be encouraged to eat and reminded of her nutritional status.  She tends to sit and never demonstrates interest in food.  She needs to be told that food is in front of her because it is questionable as to whether she recognizes objects in front of her.  She needs assistance for grooming and hygiene care.  She will need occupational therapy to help restore her dressing, grooming and hygiene skills.  She needs assistance using the toilet.  She is unable to wash below her knees at this time.

• Physical functioning and mobility.  J.H. is able to re-position herself in aim of seeking comfort while in bed.  She can ambulate 10-15 feet with maximal assistance, with a walker in therapy, but locomotes in a wheelchair.  She will need physical therapy to develop a course of treatment to improve coordination, balance, and strength especially as it relates to ambulating.  She requires moderate assistance using the toilet and transferring in and out of the bed, chair and car.

• Cognitive skills.  J.H. is unable to produce abstract reasoning, logical concept formation, and planning.  She is no longer spontaneous and creative.  She does not possess the judgment and insight required to make safe or reasonable financial, social and personal decisions.  Her memory has been compromised for both auditory and visual processing of stimuli and retrieval of information.  Although she is alert she can not sustain concentration sufficiently in order to learn.  Her deficits in concentration and memory impede upon each other when processing new information.  Both cognitive factors need to be adequate before learning is feasible.  A neuropsychologist will need to assess her higher cortical functioning and recommend treatment for recovery of her compromised skills.  She is oriented to person and to place with repetitive feedback.

• Community integration.  J.H.'s  frontal lobe syndrome has resulted in diminished spontaneity, creativity, and planning.  Therefore she does not initiate recreational activities and entertainment.She is incapable of exchanging money or making purchases.  She is unable to adequately write, however, she can hold a pen, hence she will need physical therapy to restore her fine motor coordination and strength.  The therapist's need to rule out constructional apraxia.She is unable to clean house or plan and prepare meals.  She has lost the ability to wash and iron her clothing.  Although she is able to recognize a crisis or hazard she can not perform the necessary steps to access emergency services.  The education program will need to develop a program for remedial learning of basic education skills.

• Communication.  J.H. has a basic understanding of simple conversations but can not produce or comprehend abstract thoughts.  She is capable of expressing her basic needs.  Her reading and writing skills have been severely compromised.  Basic academic skills will be addressed in the school program and speech therapy will aid in the recovery of compromised neurocognitive skills.

• Behavioral adjustment.  Inhibition of impulses has been diminished second to her frontal lobe impairment.  She is labile, easily agitated and is restless. She is emotional and cries frequently for brief periods of time for no particular reason, but is easily redirected.  She will argue and complain as a direct result of her poor ability to subdue frustration and delay gratification.  She has started to enjoy passive entertainment such as watching TV and listening to music.

• Psychosocial.  J.H. is unaware and lacks insight into her head injury.  She does not comprehend the severity of her cortical impairment.  It is suspected that the greater the understanding of her neurobehavioral deficits, the more depressed and angry she will become.  Another aspect of her frontal lobe injury is illustrated in both her lack of awareness and interest in social activities.  She will need to be reintroduced to social activities until her affability can be reinstated.  Part of Judelle's therapy program will focus on her re-integration into her mother's home, which will ultimately become the discharge site post treatment at the Florida Institute.

Progress During Course of Treatment  

J.H. has made tremendous gains in all functional areas beginning with physical functioning. At the time of discharge J.H. was independent in all bed mobility and transfers with aid of a grab bar. She is independent in all wheelchair mobility using both lower extremities.  Ms H. is able to ambulate over level surfaces and through doors independently with a rolling walker. She is able to use stairs with minimal assistance.  

As JH’s orientation and cognitive skills improved progress was rapidly made in physical functioning. Improved self-care to the independent set-up for dressing and bathing was achieved however moderate assistance for toileting with some incontinence was still evident.  J.H became aware of situations and her overall insight improved to the minimal assistance, verbal cue level.