Had been seen by me at College Harbor and started to make improvement. Started to show some vocalization where she will say no and occasionally has had some voluntary movement on command of eyes and mouth as reported by husband and mother. Ready for inpatient rehab program here at Bayfront. Physical exam shows easily startled to her name or when bedrail fell down. She will close her eyes to any threatening response around her face and blink appropriately. Tracking is inconsistent. Verbal output reported by husband and other family members and therapists at College Harbor. No voluntary movement on command at this time. Rancho Los Amigos probably about a 2, possibly 3. Responds to pain with extremity movement and moaning.
6/28/1990
Pulmonary Consult Report Dr. Thacker
Moaning type vocalizations initially; no sign of excess secretions requiring frequent suctioning; intermittently swallows, probably swallows her saliva without any trouble
6/29/1990
Neuro Consult Dr. Hernandez
Pt. is arousable and has roving eyes, altho I do not think she is following any commands. Moans, has moments of alertness. Pupils symmetrical and contents show a slight response.
7/10/1990
Progress Note Dr. Baras
Purposeful movement in right upper extremity seen by P.T., O.T. and me, but not consistent. Flexing rt. Elbow not as a reflex, but voluntarily
7/13/1990
Progress Notes Dr. Baras
Eyes open to voice, tracking, moving head toward sound, no voluntary movement consistently as yet, but does move right upper extremity
8/25/1990
Discharge Summary
Discharged from Bayfront Medical Center, pt did show some improvement in range of motion