Client Note (Tristan)
Tristan
Client ID 056
- Name
- Tristan
- Primary Diagnosis
- TBI
- Insurance
- BCBS
- Referring Physician
- M. Dominguez, MD
- Age
- 26
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- White
26yo WM with TBI sustained 9 years ago from samurai sword blade that lodged into forehead. Reports the blade breaking off the handle as he and his friends alternated tossing a plastic bottle in the air and striking it with the sword. Comatose for 2 months in acute care. Underwent craniotomy, cranioplasty, and tracheostomy. D/c to inpatient rehabilitation for 1 month. Continues to receive outpatient OT/PT.
Marital status:Single
Primary language:English
Current level of function:Partial assist for ADLs/IADLs. Completes transfers and ambulates short distances with FWW and partial assist, modified independent for manual wheelchair propulsion.
Employment/work/school:High school education. Currently unemployed.
Play/leisure/interests:Enjoys participating in adaptive sports program activities, including billiards, cycling, trap shooting, kayaking, bowling, water skiing, and surfing. Likes to listen to music and take hunting and fishing trips with his dad.
Environmental factors:Lives with dad in one-story house with 1 STE, ramp, no handrails. Walk-in shower (2” ledge), shower curtain, handheld shower head, nonskid mat, shower chair, grab bars. Standard toilet with no grab bars. Owns manual wheelchair, FWW, stander, trackchair, and parallel bars.
Outpatient OT/PT
Lamotrigine
Baclofen