Two years following his injury, V.D. underwent eye surgery to release eye muscles, plastic surgery for his face and left heel cord. He had episodes of physical aggression, hyper-agitation, immaturity, and sexual disinhibition. All of these behaviors were associated with his traumatic brain injury. Previous rehabilitation placement included a comprehensive treatment program at New Medico CRC/Apple Valley.
He has been referred to the Florida Institute for Neurologic Rehabilitation for treatment and evaluation focusing on behavioral and vocational intervention.
Comprehensive Outcome Statement
Residential: The discharge planning goal for V.D. is the placement
within a long-term community based group home providing the following
criteria:
(1) Supervision 24 hours a day.
(2) A day program and/or a supervised, structured employment opportunity
related to avocation/vocational interests of the client, specifically, the
opportunity to work around trucks and cars doing minor car service such as
changing oil, detailing, and cleaning and maintaining vehicles.
(3) Community inclusion activities allowing social interaction with others
but ensuring supervision to maintain safety for V.D. and others.
(4) The community group home must have structure and 24 hour supervision
and allow for the intermittent teaching and reinforcement of social skills
such as self-control, following instructions, accepting "no",
problem solving, consideration to others, budgeting of moneys and group
interaction related to some self government procedures.
(5) The community group home should allow for the teaching, reinforcement
and movement of V.D. towards much independence as possible in regard to
medication compliance, cooking, laundry maintenance, as well as properly
maintaining the home with other clients, separation, as well as access to
in-home activities.
(6) Community based group home should be no more than six to eight clients
to ensure enough teaching of social skills as well as attention and time
for reinforcing pro-social skills exhibited by the client.
(7) Staff must have the ability to specifically teach pro-social skills
such as instruction following, accepting "no"accepting
compliments, three foot distance, and self control, as learned by V.D.
during his treatment at Florida Institute for Neurologic Rehabilitation.
SERVICE AREA REPORTS
Please note that the short-term objectives are referenced to their
related long-term outcome goal by the "Goal #".
| Goal # | Short Term Objective |
| 1 | V.D. will engage in no more than one verbal aggression per month for three consecutive months. |
| 2 | V.D. will engage in zero physical aggressions for three consecutive months. |
| 3 | V.D. will engage in zero sexually inappropriate incidents for three consecutive months. |
| 4 | V.D. will remain on task for 90% of intervals across the reporting period. |
| 5 | V.D. will arrive on time for 90% of intervals across the reporting period. |
HEALTH Current weight: 229 pounds; as compared to 226 in July and
229 in August.
Current medications: Carbamazepine 200 mg 1 ‡ tablets three times daily
Lipitor 10 mg 1 tablet at bedtime
Ibuprofen 800 mg 1 tablet once or twice daily as needed for pain
On July 9, 1999 Dr. Juanito Corpus, MD saw V.D. and had routine bloodwork
done. The results are as follows: GGT 179 (normal 1.90), Triglycerides 406
(normal 40-200), Cholesterol 249 (normal 120-200). All other levels within
normal range. V.D. had routine bloodwork done on September 10, 1999. The
results are as follows: LDL Cholesterol, CALC 134 (normal 50-130),
Triglycerides 366 (normal 40-200), Cholesterol, Tatal 245 (normal
120-200). At this time Dr. Corpus prescribed Lipitor 10 mg 1 tablet one
time daily at bedtime to help control his Cholesterol. All other levels
within normal range. V.D. was complaining of neck pain and Dr. Corpus
ordered x-ray of his neck and back, and this was done at Florida Hospital
in Wauchula on September 21, 1999. The client had complaints of his back
hurting him after moving to TEACH. At this time an appointment was made
for him at Dr. Robert D. Halveston, D.C. V.D. continues to see Dr.
Halveston on a weekly basis for therapy.
CASE MANAGEMENT SUMMARY
During this reporting period, V.D.'s level of supervision (LOS) has
been modified several times. V.D. had a home visit to California from
7/22/99 to 7/29/99. After talking with his mother, she said the visit went
well.