PTH 745 Discharge Note Patient: Sam Howell

Patient Name: Sam Howell ICD-10 Code: 781.2, R27.8

SPTs: Conner Bruns, Ken Schirer, Grace Blankenhagen

Medical Diagnosis: Traumatic brain injury

Date of Service: 11/29/16

Date of Initial Evaluation: 11/8/16

Current Procedure Terminology (CPT) Billing Codes Units Duration (min)

97112 Neuromuscular Re-education 3 50

97116 Gait training (includes stair climbing) (timed) 1 10

SUBJECTIVE

Pt reports balance issues today due to inner ear imbalance. Reports no pain. Abrasion
noted on L wrist and minor cut noted on posterior to L ear to which pt attributes to rolling
and falling out of bed on 11/27/16.

OBJECTIVE

Vital Signs:

Position/Arm BP Heart Rate

Seated (R, resting) 112/76 108
Seated (R, post-HiMAT) 122/78 --

Outcome Measures:

- HiMAT: 18/54. Pt experienced difficulty maintaining consistent pace when asked to run,
skip, and hop. Had moderate LOB when asked to bound forward requiring stepping
strategy to remain upright. Pts course deviated consistently throughout locomotion
tasks, veering left mostly and made contact w/ wall once on L side during running. Pt
required 2 rest breaks during test.
PTH 745 Discharge Note Patient: Sam Howell

- Modified Purdue Peg Board: Pt seated on chair w/ armrests. Given practice trials w/ 3
pegs each hand before first trial. Instructed to place as many pegs in board as possible
in 30 seconds.
Trial 1 Trial 2 Description
Right 7 6 Tip-tip grasp
Left 3 6 Pad-pad grasp,
splaying of fingers
before grasping.

- Romberg/Tandem Romberg: Pt performed w/ shoes on. Required Min-Mod Ax1-2 to

maintain balance during test.
Test Time (seconds) Description
Romberg 30 Eyes open. Mild use of hip
strategy to maintain narrow
stance.
Tandem Romberg- L foot in front 30 sec Pt required multiple
attempts and displayed
excessive hip strategy but
was able to perform.
Tandem Romberg- R foot in front 10 sec Pt displayed excessive use
of hip and stepping strategy
to maintain balance.

-ABC: See attached. Pt reported decreased confidence on ABC scale w/ activities he

was previously more confident with in the beginning of care.

Interventions

Activity: Time/Reps/Resistance Description

Tibialis Anterior 3x30 Pt standing w/ feet hip width
Strengthening apart and rolled up towel under
L foot to encourage
dorsiflexion. Throws ball at
trampoline and catches.
Writing sitting on ball 3 minutes Pt seated on exercise ball w/
w/ rhythmic knees/hips/ankles at 90
stabilization degrees flexion. Pt instructed to
fill out ABC tool while resisting
perturbations on ball.
Euchre Game to first 15 minutes (1-2 minute per Pt standing in following
team to 5 points stance) positions; changed positions
every time he shuffled, dealt,
and played a hand:
- Narrow stance
- Tandem stance (L in front then
PTH 745 Discharge Note Patient: Sam Howell

R in front) facing table

- Narrow stance on foam
- Tandem stance, front leg on
foam (R in front, then L in front)
- Narrow stance, R side facing
table then L side facing table
- Tandem stance, R foot in front
and side facing table, L foot in
front and side facing table
- Standing dome side down on
half roll, hip width apart
- SLE stance, R and L
- Seated on exercise ball
- Stance w/ rhythmic initiation
Pt dealt and shuffled every
round for 6 rounds.

Boxing: 2x30 each Pt standing in tandem stance,

Jabs switch front LE every round.
Crosses Began w/ 2 rounds jabs and
then 2 rounds crosses. Called
out L and R and pt was
required to follow direction.
Soccer: Goalie 6x1 min rounds Pt standing in lunge position w/
activities blocking front LE on foam for 2 rounds.
shots Pt standing in side lunge
position w/ one LE on foam. Pt
stand in SLE stance position. Pt
was required to block foam ball
thrown at him randomly
including at midline, across
midline, and on ipsilateral side.
- Exercises chosen to improve dynamic and static balancePt experienced severe
difficulty maintaining SLE stance throughout session, requiring Mod Ax1 to maintain
upright. Requires SBA-Min Ax1 for all other activities. Pt experienced difficulty
maintaining balance when reaching for fallen objects on ground, resulting in 2 mild,
controlled falls. Required multiple attempts to place foot on foam when asked to perform
lunges and tandem stance on foam. Required consistent reminders to maintain position
or perform tasks w/ correct hand.

ASSESSMENT

Pt is impulsive and focuses on dynamic aspects of task rather than balance. Pt

experienced multiple controlled falls during session due to loss of balance running or
reaching to floor. Decreases in objective measure scores from initial evaluation possibly
PTH 745 Discharge Note Patient: Sam Howell

due to pts reported inner ear problems. Pt demonstrated improved static balance as
evidenced by the Tandem Romberg. Impairments include: balance, coordination, fine
motor skills, lack of confidence in self while performing balance tasks. Precautions: pt is
high fall risk, impulsive, and at risk for orthostatic hypotension. Pt prognosis is fair.
Skilled PT services no longer recommended as pt will continue w/ HEP at home to
improve balance and tibialis anterior strength to prevent falls.

Goals Met:

1. Pt to improve tandem stance position to 30 seconds and min Ax1 to improve

balance and decrease fall risk.
2. Pt will be independent in HEP in order to continue increasing strength, balance
and fine motor function while at home to prepare for attending school.
3. Pt will be able to ascend/descend a standard flight of stairs with only contact
guard and with proper clearance of L LE in ascension in order to increase
independence at home and to decrease risk of falls when ascending stairs.
4. Pt will be able to kick a soccer ball 5 times without losing his balance in 3 weeks
to improve his soccer playing ability.

Goals Discontinued:

1. Increase HiMAT score by 4 points to 23/54 to demonstrate MDC and improve

balance w/ perturbations so pt can feel confident walking in crowded areas.
2. Pt will demonstrate active listening skills to directions during exercises to prevent
injury and falls.
3. Improve Purdue Peg Board score by 3 pegs each to improve fine motor skills for
writing.
4. Pt will rate confidence 10% higher in all aspects of Activities-specific Balance
Confidence Scale that are below 100% in order to demonstrate increased
confidence with increased ability to complete functional tasks.

PLAN

Pt verbally consented to participate in treatment session. Pt to be discharged from

therapy today.

Ken Schirer, SPT

Conner Bruns, SPT

Grace Blankenhagen, SPT

PTH 745 Discharge Note Patient: Sam Howell
PTH 745 Discharge Note Patient: Sam Howell