Client Note (Jonathan)
Jonathan
Client ID 058
- Name
- Jonathan
- Primary Diagnosis
- TBI/SCI
- Insurance
- BCBS
- Referring Physician
- A. Hill, MD
- Age
- 42
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- Hispanic/Latino
42yo Hispanic male s/p TBI and C1-C2 SCI (ASIA D, motor incomplete) sustained 25 years ago. Underwent craniotomy, cranioplasty, tracheotomy, spinal fusion, and halo fixation. Hospitalized in acute care for 6 months, 1 month in coma. D/c to inpatient rehabilitation for 13 months. Completed outpatient OT/PT for 2 years. Does not currently receive therapy services.
Marital status:Single
Primary language:English
Current level of function:Independent with all ADLs/IADLs, no assistive device. Drives independently.
Employment/work/school:College education. Part-time tech support assistant. Work duties involve prolonged sitting at a desk and rarely lifting up to 15 pounds.
Play/leisure/interests:Enjoys participating in adaptive sports program activities including billiards, bowling, boccia, pickleball, and yoga. Attends movies or goes out to dinner with friends 2-3 times a month.
Environmental factors:Lives with grandmother in single story house, 2 STE, R handrail. Walk-in shower with fixed shower head, no grab bars. Does not currently use DME or assistive devices.
Lamotrigine