Client Note (Lori)
Lori
Client ID 061
- Name
- Lori
- Primary Diagnosis
- TBI
- Insurance
- BCBS
- Referring Physician
- S. Gunning, MD
- Age
- 58
- Gender Identity
- Female
- Pronouns
- He/him/his
- Race/Ethnicity
- White
58yo WF s/p TBI and bitemporal hemianopia, sustained from MVA 5 years ago. Underwent craniotomy and cranioplasty. Hospitalized in acute care for 2 weeks. D/c to inpatient rehabilitation for 2 weeks. Received outpatient OT/PT for 1 year.
Marital status:Divorced 9 years
Primary language:English
Current level of function:Partial assist for BADLs/IADLs. Ambulates without assistive device. Use of paratransit.
Employment/work/school:College education. Retired human resources assistant.
Play/leisure/interests:Enjoys participating in adaptive sports program activities, including cycling, rowing, billiards, bowling, boccia, and yoga. Also likes sitting on the porch listening to audiobooks and attending grandson’s basketball games.
Environmental factors:Lives with adult son and daughter-in-law in one-story house with 1 STE, no handrails. Walk-in shower (2” ledge) with shower curtain, grab bars, shower chair, handheld shower hose. Standard height toilet, no grab bars. Has an adult daughter who lives locally and shares caregiving responsibilities.
Levetiracetam