DISCHARGE SUMMARY
1. Severe traumatic brain injury with the right hemiparesis and neurocognitive deficits.
2. Longstanding seizure disorder.
DISPOSITION AND FOLLOW-UP:
Discharge to home with support from his mother and sister, as well as additional caregiver assistance, home health services, including physical, occupational and speech therapy, and nursing.
PRIMARY MEDICAL FOLLOW-UP:
Primary Care Physician within 2-3 weeks.
Rehabilitation Physician in 4 weeks.
Gastroenterology follow up for PEG tube removal in approximately 2 weeks.
SUMMARY:
Kenneth Jefferies is a 43 year-old male who was admitted to Oregon Rehabilitation Center after a prolonged acute hospitalization stemming from a bicycle accident on 07/19/2005. At that time he was found down next to his bicycle and had a severe traumatic brain injury. He required extensive ICU management for his traumatic brain injury and respiratory failure. He did end up with a tracheostomy and PEG tube. Imaging studies demonstrated multiple contusions, particularly in the left basal ganglia and internal capsule corona radiata and left temporal lobe.
He eventually improved and was transferred to the rehabilitation floor.
During his month on rehab the patient has made remarkable progress. He has gone from requiring assistance for all basic mobility and self-care skills with very low neurocognitive function to being modified independent, ambulating with a cane, modified independent with dressing and grooming, supervision for bathing and supervision on stairs. He continues to have some higher level balance difficulties. His insight has improved, and he is using a memory book. However, he continues to be impulsive with poor initiation and requires supervision for safety. He has significant memory deficits as well.
The patient was noted to have a localized PEG site infection, which was resolved with local and oral antibiotics.
At this time, Mr. Jefferies has met the inpatient rehab goals and is discharged home with the above follow up.
(All notes written by therapists)
OT:
Discussed caregiving interview this past weekend. Ken expressed feeling tired and wanting quiet time and therefore did not want to participate in the interview. One solution we discussed was for Ken to talk to his mother about questions he would like to ask, so he could still be part of the process.
OTHER IDEAS
– Plan the day’s schedule daily each morning.
– keep a schedule book of all appointments as they are made.
MOTHER IS ENFORCING RULES SET BY REHAB THERAPISTS.
9:30 PT –
Good job this morning! We worked on stairs an balance activities. Good luck at home with your recovery! It has been great working with you.