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  • Demographic Information:

    Patient is a 47-year-old, right-handed Caucasian man.

  • Social History:

    Patient is single; patient's mother lives in the area.

  • Employment:

    Patient has not been employed since his injury 2 years ago, but he previously worked for a garage manufacturing company.

  • Education:

    Patient has a college degree.

  • Living Environment:

    Patient currently resides in an assisted living apartment.

  • General Health Status:

    Patient is in generally good health, mildly overweight, with decreased activity tolerance.

  • Social and Health Habits:

    Patient leads a primarily sedentary lifestyle, is a cigarette smoker, and reports drinking five to six alcoholic beverages per week. His social network is limited to visiting his mother and other residents at the assisted living facility. He reports using a local gym occasionally.

  • Family History:

    Patient does not report any significant family history of major medical conditions.

  • Medical/Surgical History:

    Patient suffered a traumatic brain injury approximately 2 years ago during a motor vehicle collision.

  • Current Condition/Chief Complaint:

    The patient presents for outpatient physical therapy services. He reports a decline in endurance and difficulty moving his left leg. He also reports a worsening of balance with falls at home (two falls in the past 2 months).

  • Activity Level:

    Patient is independent in the home environment in all basic activities of daily living (BADL) and requires assistance in the community and for instrumental activities of daily living (IADL) (e.g., managing his finances and medications). He reports walking with a cane at times, but he also uses a rolling walker. He recently purchased a motorized scooter and reports a decrease in activity level since buying the scooter. Prior to his injury, patient was independent with all BADL and IADL.

  • Medications:

    Upon admission to outpatient services, the patient was taking the following medications: Metformin, 500 mg twice a day; Metoprolol, 50 mg twice a day; trazodone, 50 mg once a day; Zanaflex, 2 mg four times a day; hydrochlorothiazide, 25 mg once a day; vitamin B1, 100 mg once a day; Prilosec, 20 mg once a day; Reglan, 10 mg three times a day; dicyclomine, 20 mg twice a day; amantadine HCl, 100 mg once a day; Tramadol, 50 mg every 6 hours as needed; folic acid, 1 mg once a day; ibuprofen, 800 mg three times a day as needed; multivitamin, once a day; BuSpar HCl 5 mg twice a day.

Systems Review

  • Communication/Cognition:

    • Rancho Los Amigos Levels of Cognitive Functioning scale: level 7.

    • Although the patient is independent with verbal communication, he demonstrates concrete thinking, decreased short-term memory, increased time for new learning, and decreased safety awareness.

    • Learning: The patient requires multiple demonstrations of new activities, with both written and verbal reinforcement.

  • Cardiovascular/Pulmonary System:

    • Resting heart rate (HR) = 72; Exercise HR = 90; 5 minutes post exercise HR = 82

    • Resting blood pressure (BP) = 130/76; exercise BP = 146/92; 5 minutes post exercise BP = 138/80

    • 6-Minute walk ...

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