DRS Training Materials: Sample Subject

Please complete the DRS at admission, discharge, and follow-up for this sample subject.

Patient is a 32 year old white female. Patient was involved in a MVA on October 24, 1993 when she was a passenger in the rear seat of the car. The car was rear ended by another car traveling approximately 50 m.p.h. The patient had no loss of consciousness, and she was noted to be awake and combative on the way to the hospital. Upon arrival at the ER the patient was noted to be agitated and confused, speaking in word salad pattern with global aphasia.

INPATIENT REHABILITATION ADMISSION
On the day of transfer to rehabilitation, the patient was noted to be independent in eating, tolerating a regular diet well, independent in grooming and dressing. She required supervision in bathing secondary to poor balance. She was independent in toileting, continent for both bowel and bladder. She was able to get on and off most surfaces independently, however, required a shower bench for bathing secondary to decreased balance.

Patient was ambulating at least 50 feet including walking up and down a flight of stairs with supervision only. She required assistance in planning any transportation needs. Once she received help in planning, she was able to pursue the activity independently.

The patient still suffered from receptive aphasia, however, could understand basic directions and conversations most of the time without help. She spoke slowly but clearly consistently, and needed help to express her daily needs only occasionally.

Upon physical examination the patient presents as a well developed, white female who is alert and cooperative, and in no acute distress. Patient has been cooperative with the staff and other patients, however, demonstrates some minimal anxiety and frustration when confronted with new situations. She has difficulty living with her limitations, but is willing to explore new ways of adapting to her disability. Prior to the injury the patient was employed as a bookkeeper. At present she is unable to calculate serial 3's and 7's, has poor abstraction skills, and is very concrete.

By observation the patient was able to seek alternatives involving basic daily problems most of the time, requiring help only during stressful or unfamiliar conditions. She has difficulty remembering routine events and people. She is able to identify 9 out of 10 faces or events without assistance.

She is oriented to person, time and place but requires cues for her present circumstances. Throughout the examination the patient was noted to be easily distracted and required frequent cues (every 1/4 hour) to return to activity.

DISCHARGE
Discharge Date: November 17, 1993
At discharge patient was noted to be independent in all self care activities including bathing and mobility items with the exception of community mobility. After a driver's evaluation recommendations were made for the patient to abstain from driving secondary to cognitive deficits and impulsivity. It was further recommended that the patient check with another person regarding plans prior to acting on transportation needs.

Improvements noted in following areas:

Patient is now able to understand written and/or auditory communication without difficulty, demonstrating only occasional difficulty with selective abstract information. She speaks with a clear and well modulated voice, again, has occasional difficulty with work finding in selected abstract discussions.

Her reading and writing skills have improved significantly. She appears to completely understand complex ideas and is able to write clearly and legibly with no more than average errors.

The patient has shown decreasing agitation and restlessness with improvement in concentration. She responds positively to constructive feedback.

The patient occasionally exhibits depression, anxiety or frustration and actively seeks to compensate when faced with some of her limitations.

Patient is recommended not to return to work for approximately 3 to 6 months, and that she receive speech therapy and occupational therapy to address some high level work skills and pre-vocational skills. However, the patient feels that she is able to return to work in a much shorter time.

The patient is actively participating in high level self care tasks requiring cues only rarely for complex tasks such as balancing her check book. She continues to have difficulty remembering routine requests and familiar names. She is able to compensate by utilizing her memory book and other strategies consistently. She is oriented x 4 without cues, however, continues to be easily distractible. Her attention can be as much as 30 minutes per task then requires cues for redirection.

Other recommendations for the patient are that her sister and boyfriend assist by daily phone contact initially after discharge.

FOLLOW-UP
Date: May 12, 1994
The patient was seen and examined at the outpatient clinic on this date. She was discharged from the comprehensive rehabilitation program in November, 1993. Presently, the patient is independent in all of her self care activities. She has a valid driver's license from the state of California. She has successfully resumed her social life. Patient recently obtained employment working for a business in which her duties include client and office personnel interaction and planning and communications skills. She states that she has been very frustrated in the first week of work because she is unable to understand much of the complex information, and has mild word finding problems. Patient also noticed that she had difficulties in sustained concentration, and learning and memory for new information.

Her present plan is to continue orientation and attempt to maintain her present job with the understanding that if she is unable to compensate in her present work, she will refer to the Department of Rehabilitation for assistance.

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