CT SCAN OF THE BRAIN WITHOUT CONTRAST:
FINDINGS: Partial opacification of ethmoid sinuses compatible with ethmoid sinusitis. No acute fractures identified in the skull base. No evidence of depressed skull fractures. No focal scalp soft tissue swelling.
Rounded area of high attenuation involving the left basal ganglia. It measures roughly 9 x 7 mm and has Hounsfield measurements rangng from 40 to 60. A similar focus, though smaller measuring 3 mm in the head of the right caudate nucleus.
These focal areas of high attenuation are not significantly associated with mass effect. No evidence of midline shift. No extraaxial abnormality. Question whether these represent focal areas of hemorrhage involving the basal ganglia. Question whether the patient has had anoxic brain injury.
Upon further review, the high attenuation lesion in the left basal ganglia most likely represents focal hemorrhage. Without a history of trauma, a hypertensive invent may preclude the patient to hemorrhage in this location. Minimally displaced fractures are noted involving the right zygomatic arch and lateral wall of the right orbit.
End of Diagnostic Report.
(All notes written by therapists)
Righty listened well when touching cones. Went a a long walk- did great!
9:00 OT “I used my right hand and put pins in holes. It was difficult, my arm was strained.”(written by S.T.)
11:30- Speech
– added a practice sheet
– reviewed info in this book
– practice shoulder exercises
Lunch- in room as usual, tired. Sister here for lunch.
3pm- PT good job with balance activities. Another long walk this afternoon.
Right arm exercises
Fine motor activities
– crumple up paper
– flicked cotton ball across table
– built block towers
Phone book activity
– Make sure to read phone # accurately.
9:30 PT: “Righty” did great this morning!
worked on balance and step ups.
Speech-
helped you make a list of pros and cons about which therapy would be best after going home.
3pm PT: Good job this afternoon. We took a long walk back to your room!
11:30 Speech
practiced completing sentences
plans for after hospital
We reviewed your schedule. You are much better with your memory.
2:30 OT
It’s okay to ask people to repeat themselves so that you understand what they are saying.
Review Home Safety Recomendations.