Acacia Rehabilitation Institute, Tucson Arizona

Occupational Therapy Initial Evaluation
Acacia Rehabilitation institute

Date:  07/02/2011

S:  “This totally sucks…they say I shouldn’t get out of bed without help…..but they never come when I call them.”  Pt c/o pain of an 8 on a 10 pt scale.  He states his wife is “paranoid” about his use of Percocet for pain control because she had a friend who became addicted to it many years ago and the friend committed suicide.  Pt states his main goal is “to be able to do everything I can for myself so my wife will not have to take care of me.  We have three kids who deserve her attention more than I do.”  Later pt said, “it freaks me out that I might not be able to work if I don’t get way better than I am now.”

0:  Orders for OT received.  Chart was reviewed which includes some records from hospitalization in Germany, and then Gila Hospital here in Tucson.  Pt had injuries from IED explosion in Afghanistan where he was working as a photojournalist.  He had multiple injuries including a L skull fx, L facial injuries, L arm injuries and L femur fx which required repair and is now with an external fixator and PWB according to PT notes.  Pt developed intermittent seizures while at Gila Hospital and is now on dilantin for that.   Records from Gila Medical Hospital indicate he was max A for all ADL and IADL, had pain and edema in UEs with risk of contractures, poor activity tolerance, low endurance for ADL, and with limited attention span.  He was able to follow 1 step commands some of the time upon admission there and DC notes indicate he made some significant progress in his ability to sustain attention once he was fully weaned from sedation.  At time of DC he was able to wash his UEs in W/C at sink with supervision and contact guard for safety with PWB.  Endurance improved somewhat and he develped increased ability to sustain attention during tx to 1-2 hours.    Has hx of MRSA. 

The following evaluations were performed today:

MMSE II  Raw score of 11 out of possible 16.  He was unable to recall any of the 3 words he was asked to remember, and believed he was still  at Gila Hospital.

He can currently comb his hair and wash his face with mod assist.  He can self feed certain foods such as mashed potatoes but is unable to cut meat.  Due to dental injuries he can only tolerate a mechanical soft diet.  He could probably self feed finger foods such as sandwiches but due to dental injuries that is not practical.  He is especially motivated by various popsicles, especially “bombpops”  and jokes that he would “like to drop a bomb pop” on those who are responsible for his injuries. He says the popsicles do help to decrease mouth pain.  He finds the small sticks on the popsicles difficult to grip with R hand and so OTR recommends using drumstick ice cream treats and other cone shaped treats instead. OTR explained idea of using built up handles for now to compensate for his painful and impaired grasp.  OTR requested wife Nancy  bring in patients favorite and most comfortable clothes including some shorts, a button down shirt, a T shirt and a Polo shirt.   Wife reports she has done the retrograde massage to pts hands and PROM fairly regularly while she has visited him.  She verbalized concern that he is overusing Percocet and could get addicted.  He told her she was being a ‘worry wart” and said he needed the meds in order to be able to tolerate therapy.  OTR reviewed and reinforced recommendations from previous OT regarding approaching the bed from various angles in order to facilitate visual tracking and the use of calendars and clocks and matter of fact orientation.  Wife was advised to avoid asking him if he knows what the day is, and instead just embed that info within the conversation in a matter of fact way in order to decrease anxiety/agitation. 

The following issues will be addressed by OT:

1.     Mod to Max A all ADL and IADL.
2.     RUE edema,  incomplete grasp, particularly MCPs that prevent full grasp on smaller ADL objects, such as feeding utensils and toothbrush. 
3.     Inconsistent orientation to place and time
4.     Impaired memory for recent events
5.     Impaired coordination of R UE
6.     Low endurance interferes with ability to sustain ADL to completion
7.     Incomplete occupational profile due to pts previous difficulty attending and communicating.  Wife has not yet completed the Modified Interest Checklist as requested by OT at Gila Hospital.  

P:
Pt will require extensive skilled OT daily, 2x a day for at least 1-2 months

Goals for this setting by time of DC include:

1.      Increase independence in ADL to
         a.      Min A UE dressing
         b.     Mod A LE dressing
         c.     I  sponge bath at sink in W/C with PWB L LE
         d.     I mouth care
         e.     I hair combing and shaving with electric razor
2.     Wife to continue UE PROM and retrograde massage.  Pt to begin self ROM and retrograde massage to RUE  Pt will keep hand higher than heart when practical to do so.  Pt /wife will compensate for poor grasp with larger handles on ADL objects.  OTR will build up handles on brush and toothbrush. 
3.     Pt will begin use of a daytimer to track important events.   Wife will insert important events up until now and then pt will continue. 
4.     Pt will be able to manipulate small objects such as cell phone and computer keyboard
5.     Pt will consistently report correct time and place
6.     Increase completion of occupational history and profile including leisure, social and  spiritual dimensions. 
7.     Wife will attend “new beginnings” occupational therapy group to explore methods to adjust to changes in her spouse. 

Medical Admission H & P
Acacia Rehabilitation Institute, Tucson, AZ

Date: 7-1-2011

HPI:
Patient is transferred to Acacia Rehabilitation Institute from Gila Hospital for treatment following blast injuries sustained 4/19/2011. He was embedded with an American military unit and on patrol when an IED exploded near left side of vehicle. Patient sustained blast injuries to left face and ear, left shoulder, left chest, left flank, and a compound left lower extremity fracture.

After being stabilized in local Military hospital in Afghanistan and placed in a medically induced coma he was then transferred to Landstuhl Regional Medical Center in Germany on 4/21/11.

Care in Germany included: external fixation of the compound, left mid-shaft fracture; observation and monitoring for pulmonary contusion complications and resolution; dental evaluation for broken teeth, reconstructive repair of left pinna; monitoring for closed head injury; and debridement and wound care for superficial lacerations, contusions, and abrasions. Brain MRI revealed left frontal-temporal-occipital punctate hemorrhages.

While in Germany, the patient developed pneumonia which resolved; was placed on Vancomycin for osteomyelitis; and was placed on Dilantin for intermittent seizures.

Patient was then transferred to Gila Hospital, Tucson, AZ on 6-24-11. Vancomycin, Rifampin, Dilantin, and pain medications were continued. An interim, removable partial dental appliance was constructed. Contractures developed in the upper and lower extremities and there was persistent edema of the right hand. He also received a diagnosis for depression that was treated with Effexor, 75 mg qd. Pain was controlled with oral Percocet and Ibuprofen.

PMH:
Childhood ills: mumps, chickenpox, and croup.
Adult Ills: No HTN, DM, renal or pulmonary concerns, no hyperlipidemia
Medications: Percocet prn pain, IBU up to 800 mg tid prn, Dilantin, Effexor 75mg qd, vancomycin and rifampin, daily multivitamin, occasional melatonin for sleep and Echinacea when he feels cold signs and symptoms
Allergies: NKDA
Immunizations: Td 4/19/11 Afghanistan
Past Surgical Hx: Appendectomy age 12, squamous cell carcinoma mole removed, left cheek 2002, no sequellae, external fixation of left compound femoral fracture, left pinna reconstruction, multiple dental extractions, debridement and wound care.
Family Hx: MGF (maternal grandfather) died, age 87 with CVA (Cerebrovascular accident), HTN (hypertension) ; MGM (maternal grandmother) alive at age 92, no known illnesses; PGF (paternal grandfather) died age 56 in coal mine collapse; PGM (paternal grandmother) died age 76 with CVA, DM (diabetes mellitus), and HTN. Mother alive, age 74 with hypothyroid, depression. Father alive, age 76 with HTN, hyperlipidemia, and gout. No siblings. 3 children, ages 10, 5 and 4 without illness.
Social Hx: Married, heterosexual, works as correspondent, no tobacco or illicit drug use, occasional ETOH (1-2 glasses of red wine each night when not travelling)
Religion: agnostic

PE:
General: well-developed, adult male with recent weigh loss, in mild discomfort.
Mental Status: Alert and oriented to person, time, and place. Conversant and able to follow conversation.
Vitals Signs:  Pulse 86, Respiration 10, BP 128/82, Ht: 6’0”, Wt: 233#
CRANIAL NERVES:  III - XII assessed and found to be grossly intact with the exception of decreased hearing and right visual field loss. Sensory grossly intact to light touch.

HEENT:  
Ears: Non-erythematous scar of the left pinna. Left tympanic membrane perforated, no d/c or swelling in EAC (external auditory canal), Right TM pearly gray and mobile, no swelling or d/c in EAC. Unable to test hearing at this time.
Eyes: No periorbital edema or bruising, lids atraumatic, PERRL, conjunctiva- white, non-injected, non-erythematous;  EOM grossly intact
Nose: Nares patent, no bleeding or d/c, septum midline.
Mouth: Several broken teeth left upper and lower jaw, tongue atraumatic, pharynx non-erythematous.
Face: no palpable deformities in mandible or facial bones
Neck: Trachea midline without shift; thyroid non-palpable, carotid upstrokes normal bilaterally with no bruits, no cervical adenopathy appreciated.

Chest:  Lungs clear to auscultation bilaterally. No dullness or tympany noted to percussion.
Cardiac:  RRR with no S3, S4, or murmurs.  PMI at the left 5th intercostal space with no palpable thrills.
Abdomen: Bowel sounds present in all 4 quadrants- soft, non-tender, and without rebound or guarding, or distension. No organomegaly noted. Rectal exam-normal.
Back:  No obvious injury, malformation, or deformity of the back. No costo-vertebral angle tenderness noted bilaterally.
GU:  Normal adult male; circumcised, testes palpable without masses; no discharge or lesions noted.  Rectal: prostate: symmetric, no nodules
LUE: No apparent deformities or fractures
RUE: No apparent deformities or fractures, full PROM, intact equal pulses, persistent edema.
LLE:  External fixation device on the femur.  Noted erythema of several pin insertion sites. Distal pulses intact, symmetric at 2+/2+.  DP/PT pulses bilaterally equal.   Skin of distal extremity exhibits normal color and temp. Restriction of passive ankle dorsiflexion, knee extension, and hip extension. Left inguinal adenopathy appreciated.
RLE: No apparent deformities or fractures, full PROM, intact equal pulses, no edema.

Impression:

1. History of closed head injury with multiple punctate hemorrhages.
2. History of left temporal fracture- good approximation and healing
3. Compound fracture, midshaft, left femur-externally fixed healing by secondary intention due to infection. POD # 67
4. Left parietal scalp laceration-healed
5. Perforated Left TM
6. Laceration, left pinna-reconstructed
7. Abrasions- left face, left chest, left scapula, left flank/abd, left leg-healed
8. Pain and restriction of multiple joints of left lower extremity
9. Pain and restriction of left shoulder
10. Osteomyelitis-active

Plan:
1. CXR, EKG, CBC, CMP, UA, Dilantin level
2. Repeat brain MRI to check punctate hemorrhages
3.  IV access
4. Audiology consult
5. Dental consult as needed
6. Physical therapy consult
7. Occupational therapy consult
8. Speech and language consult
9. Continue Dilantin, Effexor, Percocet prn and IBU prn

Admission Osteopathic Palpatory Evaluation
Acacia Rehabilitation Institute

Head: Left occipitomastoid restriction, left occipital condylar compression
Cervical: C2Rl, C4ERrSr, hyoid left, increased paravertebral muscle tone C3-5 right more than left. Tender anterior right C5 tenderpoint.
Thorax: counterclockwise sternomanubrial rotation, xiphisternal restriction, T1-3NRrSl,  increased trapezius and rhomboid tone left
Lumbar: increase muscle tone left greater than right; right greater than left psoas tone L5ERlSl
Sacrum: right sacroiliac restriction, sacral torsion
Pelvis: Inferior left ASIS, superior left pubic tubercle, left piriformis and gluteal tone increased
Lower extremities: internal left tibial torsion, anterior left fibula head, mild popliteal tightness, posteriorly rotated left innominate
Upper extremities: mild edema right hand, right interosseous restriction, posterior right radial head, tenderpoints right pronator and multiple dorsal carpal.

Impression: See initial medical H and P for this facility
1. Multiple somatic dysfunctions of the head, cervical, thorax, lumbar, ribcage, sacrum, pelvis, upper and lower extremities.
2. Muscle spasm and contractures
3. Gait disturbance
4. Cognitive difficulties with depression
5. Seizure disorder

SBAR Report Nursing - Acacia Rehabilitation Institute

Jones, Charles Robert (Chip)  MRN:  349213

Date:  July 1, 2011
38 year old Male
Admitting physician:  Dr. Jones
Code status:  Full Code
Allergies: NKA
Weight:    106.8kg/ 235lbs at time of injury      Height: 6’ / 72”
            Now:  88.63kg/195 lbs
Admitting Diagnosis:  Osteomyelitis

Brief History of hospital course: Riding in Humvee on photo shoot with Marine Corp, struck by improvised explosive device (IED).  Sustained serious injuries to left side of body including arm, leg, chest, and head/face.  Spent time in Landstuhl General Hospital,  then spent a week in Gila Hospital in Tucson.  Patient is now admitted to Acacia Rehabilitation Institute to continue treatment for osteomyelitis and rehabilitation for injuries sustained overseas.   
Current Medical Issues:  seizure disorder, depression, perforated left tympanic membrane, extremity contracture and restrictions, status post external fixation for an open, infected left femoral fracture with osteomyelitis, status post multiple lacerations and abrasions-healed, status left temporal fracture-healed.
Family/Social Concerns: Wife, Nancy stay at home mom, and 3 children under 10 living in Tubac, Arizona
His parents live in Tucson, and wife’s parents live in Tubac. Patient is a war correspondent and is a photo journalist.
Contact precautions:  MRSA in Left leg wound.
Fall and seizure precautions
 

Clinical Assessment

Functional Health Patterns

Health Perception/Health Management    
Subjective:  Patient states “I want to work hard to get better and go home”
Objective:  Patient tires easily when attempting to do physical therapy, occupational therapy or basic ADL’s. 

Values and Beliefs 
Subjective:  Patient states “My family is very important to me and that is what keeps me going”
Objective:  Patient smiles when he speaks about his family and watching his children grow up.    

Cognitive/Perceptual 
Subjective: Patient states “I normally learn  by hearing, but since my hearing is bad, I have taken to seeing to learn”
Objective:  Patient learns by seeing how to do things and questions things over and over due to his hearing loss.    

Nutrition/Metabolic    
Subjective:  Patient states “Food just doesn’t taste the same with all the medications I’m taking and I have lost my appetite.  Nothing sounds good”
Objective:  Patient is encouraged to take in supplemental drinks to help with nutrition.    

Activity/Exercise    
Subjective:  Patient states “ Before I got hurt I used to jog everyday for 2 miles”
Objective:  Although tired patient is willing to work with physical therapy.    

Elimination 
Subjective:  Patient states “I feel that my elimination was normal prior to the accident but now I have to take medications to have a regular pattern”
Objective:  Patient is given medication for constipation on a regular basis and complains of constipation often. 

Sleep/Rest 
Subjective:  Patient stated “Prior to the accident I slept 6 hours per night and never felt sleepy during the day. Now I feel like I can sleep all of the time.
Objective:  If patient is not engaged with visitors or hospital staff he is sleeping    

Role/Relationship 
Subjective:  Patient stated “I was the head of household when I would be at home and not traveling on assignment. My wife would then take over the role. Now I feel she will always be in charge, and right now I am okay with that”
Objective:  Wife discusses issues with her husband but seems to hold back on some things due to fear of upsetting her husband and has expressed this to the nursing staff. 

Coping/Stress 
Subjective:  Patient states “I’m so stressed with being injured and not being able to handle the stress of life outside of here in the hospital working on getting better.”
Objective:  Patient seems to be sad at times when his family leaves after visiting.    

Self-perception/Self concept 
Subjective: Patient states “I feel like I am out of control of my personal life and my family life since the accident.  Prior to that I was very in control of my emotions”
Objective:  Patient sometimes gets frustrated when trying to do things for himself. 

Sexuality/Reproduction 
Subjective:  Patient stated “I do not feel comfortable discussing this subject”
Objective:  Patient blushed when asked the questions.

Acacia Rehabilitation Institute

Tooth #5 fractured due to fall. No symptom was associated with the tooth.
Pt was referred to make appointment for dental examination 
 

X-Rays Taken After Fracture of Facial Cusp on #5

Speech/Language Therapy 
Acacia Rehabilitation Institute – Tucson, AZ

Initial Evaluation – 7/2/11

S: Pt admitted to Rehabilitation Institute from with orders for speech therapy assessment.

O: Chart reviewed.

History: The Pt was treated in Gila Hospital from 6/24/11 through 7/1/11 as the result of multiple injuries sustained in an IED explosion while stationed as a photojournalist in Afghanistan. From the trauma site he was transferred to a hospital in Germany from 4/21/11 – 6/24/11 returning stateside to Gila Hospital. Injuries included closed head injury (CHI); L temporal Fx, L frontal-temporal-occipital lobe punctate hemorrhages; L tympanic membrane rupture, multiple contusions and lacerations/abrasions of L scalp, face, ear, flank, leg, shoulder, chest and abdomen; contaminated, open L mid-shaft comminuted femur Fx; broken teeth; and pulmonary contusion. He initially was GCS 10. He was intubated until 4/30/11. He developed pneumonia on 4/27/11 which has since resolved. He has a Hx of MRSA and osteomyelitis in the L LE. He was placed on Dilantin for seizures that occurred on 5/15/11. In addition the Pt c/o tinnitus that reflects the involvement of the L temporal lobe.

Precautions: MRSA L LE; Hx seizures; R visual field cut; decreased cognitive functioning.

Formal Assessment of Cognitive/Linguistic Skills: Portions of testing completed in Gila Hospital were repeated. 
Auditory comprehension: It was noted that the Pt is now able to follow 2 and 3-step commands but breakdown occurs with increased complexity and length. 
Verbal expression:  The Pt was able to name objects on the Boston Word Finding test with accuracy that was WFL, but responses were abnormally delayed. Connected speech remains somewhat telegraphic, but the Pt is able to express his wants and needs, but perseveration and ongoing semantic errors remain. 
Reading comprehension: The Pt was able to adequately attend in order to complete a full Reading Comprehension Battery for Aphasia. He scored 100% on the word and phrase level. His performance on functional reading and sentence comprehension was 90% and 80% on sentence level comprehension. His difficulty occurred on implied information on short stories showing inability to make inferences. He also was unable to comprehend morphological and syntactical markers to comprehend sentences describing pictures. 
Written expression: The Pt was able to write out biographical information, but had great difficulty with generating sentences on request. His performance was hampered by his motoric limitations of his preferred arm. 
Cognitive Assessment: The Ross Information Processing Assessment (RIPA) was administered resulting in the following:

Immediate Memory……………………90%
Recent Memory    ……………………..90%
Temporal Orientation (recent) ……..90%
Temporal Orientation (remote) …….70%
Spatial Orientation…………………….90%
Orientation to Environment………..100%
Recall of Generation…………………..90%
Problem Solving and Abstract Reasoning………    75%
Organization……………………………100%
Auditory Processing and Retention…80%

A: The Pt exhibits ongoing mild to moderate aphasia involving all language modalities – verbal and written expression and auditory and reading comprehension. Reading comprehension is compounded by his right visual field cut. In addition he exhibits mild to moderate cognitive issues including immediate and remote memory and temporal orientation (recent) and spatial orientation (mild) and moderate involvement of temporal orientation (remote), problem solving and abstract reasoning, and auditory processing and retention.

P: Treatment goals will be to:
1.     Improve word recall in order to express thoughts, feelings, and ideas.
2.     Improve auditory comprehension for following complex directives in order to follow medical and therapeutic recommendations.
3.     Improve reading comprehension in order to participate in functional activities for daily living skills (ie reading paper, product labels, TV guide, etc.).
4.     Improve auditory attention to tasks to encourage improved auditory processing and retention of information.
5.     Address written expression when the Pt’s UE movements are not painful.

Physical Therapy
Acacia Rehabilitation Institute – Tucson, AZ

Initial evaluation 7/2/11

S: Pt lying semireclined in bed, external fixator left (L) lower extremity (LE).

O: History: Patient admitted 7/1/11 from Gila Hospital where he was an in-patient 6/25/11-7/1/11. Previously he was in a hospital in Germany 4/21/11-6/24/11 for treatment of multiple injuries from an IED in Afghanistan 4/19/11. Injuries included, closed head injury (CHI); L temporal fracture; L frontal-temporal-occipital lobe punctate hemorrhages; L tympanic membrane (TM) rupture; multiple contusions and lacerations/abrasions of L scalp, face, ear, flank, leg, shoulder, chest and abdomen; contaminated, open L mid-shaft comminuted femur fracture; broken teeth; pulmonary contusion. Glasgow Coma Score of 10 initially and patient in medically-induced coma for transport to Germany. Intubated and on ventilator initially, and extubated 4/30/11. External fixator applied to L femur fracture 4/24/11; fracture remained open for healing; wound now closed. Developed pneumonia 4/27/11 (resolved); MRSA and osteomyelitis (on Gentamycin) L LE; seizures 5/15/11 (on Dilantin); c/o tinnitus. 
Social: Married, 3 children, worked as a photo journalist. 
Precautions: MRSA L LE; History of seizures; Partial weight bearing 50 lbs. (PWB) L LE. 

Examination findings:
Cognition/language: Alert, oriented to time, place and person. Consistently follows simple verbal instructions, but occasional problem with complex verbal instructions. Utters several words appropriately in response to questions, but sentences are incomplete.

Sensation: Light touch appears intact right (R) upper extremity (UE), R LE, L UE, and distally L LE. Occasionally runs into objects on R when propelling wheelchair.

Motor: PROM intact R LE, L UE, R UE except mild limitation R MCP flexion and edema MCPs; L LE: Hip flexion 10-90 degrees, knee flexion 10-80 degrees, ankle dorsiflexion -5 degrees. 
Tone: Mild increased flexor tone R UE and mild increased tone R plantarflexors, otherwise normal. 
Strength: R UE 4/5, R LE 4+/5, L UE 5/5; L LE: 4/5 hip flexion, 3+/5 knee extension, 5/5 ankle dorsiflexion/plantarflexion. Pain 4/10 rating on PROM/AROM L knee. 
Balance: Able to perform simple functional activities sitting at edge of bed with supervision and no loss of balance. Maintains standing with FWW, PWB L LE with minimal assistance.

Mobility: Minimal assistance moving supine to sitting at edge of bed. Maintains sitting at edge of bed with supervision. Minimal assistance for sliding board bed, chair, commode transfers, transferring to R. Modified independence manual wheelchair propulsion 300’ level surfaces; supervision for propelling wheelchair on minimum grade ramps. Able to tolerate sitting for 2 hours before requesting to go back to bed. Ambulation with FWW 300’ level surfaces with minimal assistance, PWB L LE. Minimal assistance up and down one 6” step with FWW.

A: Major impairments and activity limitations include:
1)    Occasional word finding problems. Consistently follows simple verbal instructions, but occasional problem with complex verbal instructions
2)    R visual field cut
3)    R UE and LE weakness
4)    L LE limited PROM, strength and pain due to femur fracture
5)    Impaired balance in standing and walking
6)    Limited endurance
7)    Minimal assistance for all mobility. PWB L LE

Goals:
1)    Increase strength R UE and LE to 5/5 for increased use in ADLs.
2)    Increase PROM R knee flexion to 90 degrees flexion, R hip and knee extension and R ankle dorsiflexion to neutral (0 degrees).
3)    Supine to sitting with supervision.
4)    Standing pivot transfers to bed, chair, commode with supervision, PWB L LE.
5)    Modified independence manual wheelchair propulsion all surfaces.
6)    Ambulation with FWW 500’ level surfaces with supervision, PWB L LE.
7)    Supervision up and down one 6” step with FWW, PWB L LE.
8)    Patient’s wife able to assist patient with all mobility independently.

Plan: Therapeutic exercise and mobility training 2x/day.