IPE-Interprofessional Cross-Campus Collaborative Case

Your Team Task

Your team is about to take over the care of Jamal “JT” Taylor who was seen in the Emergency Room following a motor vehicle accident. He presented with headache, jaw pain and shoulder pain and was diagnosed with mild traumatic brain injury with loss of consciousness (concussion), temporomandibular joint dysfunction, and acute shoulder strain deltoid (L).

You are provided with the following information to help you with your task.

• Audio and written narratives from JT and his Auntie Rose.
• A description of JT’s home town.
• Documentation from the health professions involved in JT’s care during his Emergency Room visit and following discharge from the ER.

Your team is tasked with:

• Identifying the holistic needs of JT and his family.
• Building an interprofessional team with the skills to meet the needs of JT and his family

As you work together to build the team to care for JT and his family you must consider:

• The holistic needs of JT and his family.
• How you can place the interests of JT and his family at the center of the interprofessional team.
• The composition of the interprofessional team, identifying the roles and responsibilities of those involved and how they relate to the identified needs for this family.
• Specific team strategies you will use to ensure the interprofessional team functions as an effective team.
• Specific communication strategies the team will use to ensure they practice effective interprofessional communication.
• ​How quality improvement and patient safety will be addressed by the team.

Core competencies for interprofessional collaboration

Use the 4 core competencies for interprofessional collaborative practice to guide you on the issues to consider:

1. Work with individuals of other professions to maintain a climate of mutual respect and shared values. (Values/Ethics for Interprofessional Practice)
2. Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. (Roles/Responsibilities)
3. Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. (Interprofessional Communication)
4. Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. (Teams and Teamwork)

Teams

Once you register for the collaborative event, you will be placed into a small interprofessional team and will be assigned a team facilitator. Names and contact information for your teammates and facilitator will be sent to you prior to orientation. By the end of the orientation event, your team should have developed a plan as to how you will communicate and function to complete the assigned tasks.

Interaction with Facilitators

A faculty team facilitator will be assigned to each team. The faculty team members who developed the case will serve as facilitators for your group and can help guide you through the task. So please feel free to ask for help in understanding the assigned task. ​Your facilitator is able to:

• Provide feedback/guidance to your team as you work through the case and prepare your presentation.
• Review your plan/presentation prior to your final team presentation.
• Provide feedback and comments during your practice session.

The Presentations

Your end product is an oral presentation, presented via Zoom, which demonstrates your reflection on the life story and care of JT Taylor and his family, and the professionals you would include in an interprofessional team to meet their needs.

You are also asked to provide a short reflective piece in your presentation on your own team's experience of collaboration in action, including what you have learned about the other professions' roles and responsibilities, team working, and communication issues.

Presentation Structure

Each team will have 20 minutes to present their work. A 5-minute, 3-minute and 1-minute warning will be given to the team. At the conclusion of 20 minutes, the timekeeper will announce time and your team must stop their presentation. No team will be permitted to exceed the allocated 20-minute time limit. If the team completes its presentation prior to the 20-minute time limit, the team should announce that they have completed their presentation. Presentations will be followed by a 10-minute question and answer period with a panel of judges.

Each team member must participate equally in both the oral presentation and the question and answer period immediately following the team presentation.

Teams may invite friends and other students to attend their presentation. By the time of your scheduled rehearsal, please let your facilitator know the names and email addresses of any people you would like to invite. The audience may include other non-participating students, faculty, and interested health professionals. Audience members are requested not to ask questions or use the chat feature during the presentations.

Judges will complete a scoring sheet for each team presentation. An average score will be calculated for each team. Teams will be provided with their team score and feedback after the event.

Grading Rubric (download)

About Jamal "JT" Taylor (The Case)

Listen to JT’s Emergency Room narrative (audio file)
Read JT’s Emergency Room narrative (pdf)
Listen to JT’s post-accident narrative (audio file)
Read JT’s post-accident narrative (PDF)
Listen to JT’s Auntie Rose’s narrative (audio file)
Read JT’s Auntie Rose’s narrative (PDF)

JT's home town of Kirksville, Missouri

Kirksville is home to Moberly Area Community College, A.T. Still University’s medical and dental schools (Kirksville College of Osteopathic Medicine and Missouri School of Dentistry and Oral Health) and to Truman State University, a liberal arts and sciences university where JT is currently a senior. A.T. Still University (ATSU) of Health Sciences is the founding institution of osteopathic healthcare. The colleges and universities provide diversity to the community including opportunities for community attendance at sporting, lyceum and concert events.

For healthcare, Kirksville is home to Northeast Regional Medical Center, a 93-bed facility with a Level III trauma center and Certified Chest Pain Center. Northeast Regional Medical Center also offers outpatient rehabilitation programs for physical therapy, occupational therapy, speech language pathology and cardiac rehabilitation. There are a number of general practice and specialty clinics, including Northeast Regional Health Council, a comprehensive, not-for-profit center offering primary and behavioral health, dental services, veterans services, pediatric and OB-Gyn and internal medicine services. The Health Council provides most services on an income-based sliding scale. Complete Family Medicine operates an urgent care clinic in Kirksville that is open 365 days a year from 8 am to 8 pm, providing an alternative to expensive Emergency Room care for a number of conditions.

The Adair County Health Department provides a variety of environmental and home health care services in the county, including a range of diagnostic, laboratory and medical care services, testing, immunizations, home visits, occupational and physical therapy, breastfeeding support and more. They also provide communicable disease surveillance and investigation.

Chariton Valley Association supports and advocates for individuals with disabilities. They provide supportive housing and homecare services.

For outdoor recreation is nearby Thousand Hills State Park, which features a lake and outdoor activities such as swimming, fishing, boating, hiking and mountain bicycling. There is also the Kirksville Aquatic Center, which offers indoor/outdoor swimming and pool activities year-round, in addition to various classes. Local parks provide walking trails and opportunities for frisbee golf, labyrinth walking, skateboarding, and general play. The City Parks and Recreation Department sponsors various opportunities throughout the year, including dinner theaters. The Adair County YMCA offers a wide range of sports and wellbeing opportunities for children and adults and also provides after-school childcare services. Scholarships are available to support YMCA programming based on income eligibility.

Through support of the local community, every Saturday throughout the summer, a Farmers’ Market is operated on the “square” in downtown Kirksville. Also, free concerts with local musicians occur every Friday evening. The local 4H community supports the Northeast Missouri Fair, with livestock and various farm displays as well as pageants and well-known music artist performances.

Nursing home services are provided at Kirksville Manor Care, The Pines and Highland Crest Senior Living. Highland Crest includes a special unit for Alzheimer patients.

JT Taylor’s emergency room visit

Northeast Regional Hospital
12/29/22 0930


Subjective
HPI:
Jamal “JT” Taylor is a 22 year old male Truman State student who arrived via EMS after rollover MVC. He was the restrained driver in his 4 door sedan. Airbag reportedly deployed. He was accompanied by his roommate who was the passenger. EMS reports he was alert and oriented to person, place, time, and event when they arrived on the scene. He does not remember the entire crash so they suspect loss of consciousness. He reports headache, jaw pain, and shoulder pain that began immediately after the accident. He reports all of these as dull throbbing and rates them at a 7/10 pain. He denies radiation of the pain or any associated symptoms other than some mild nausea and feeling like his brain is “sluggish”. He reports the light worsens his headache some but otherwise denies exacerbating or relieving factors. He has never had symptoms like this before.

Medical History:
Hearing Impairment. Hx of hearing aid use. Not currently utilizing hearing aids.

Surgical History:
None

Social History:
Occupation: Truman State Student & athlete
Tobacco Use: Never smoker
Alcohol Use: Socially, 3-5 beers a weekend
Drug Use: Denies ever using drugs

Family History:
Father - Hypertension, Deceased
Mother - Hyperlipidemia, Deceased
Paternal Grandfather - Colon Cancer, Deceased

Objective
Medications
None

Height: 6’ 8”
Weight: 225 lbs (102 kg)
P: 124
BP: 142/88
RR: 20
SpO2: 98% on room air
T: 99.1 F

Neurological: Pupils equal, round, and reactive to light. Cranial nerves 2-12 grossly intact, sensation grossly intact in the bilateral upper and lower extremities. Glasgow Coma Scale 12 out of 12
Cardiovascular: Tachycardic but regular, 2/4 in the bilateral radial and dorsalis pedis arteries. No murmurs, gallops, or rubs.
Pulmonary: Clear to auscultation bilaterally, tachypneic but respiratory effort non-labored, chest movement symmetrical.
Gastrointestinal: Bowel sounds normoactive, no tenderness to palpation, rigidity, guarding, or rebound tenderness.
Musculoskeletal: No obvious bony deformities. Some tenderness to palpation of the jaw and left shoulder. Pelvic girdle appears stable.
Dermatological: Bruising noted over the left shoulder and right anterior hip consistent with seat belt trauma.

Assessments
Mild traumatic brain injury with loss of consciousness (Concussion)
Temporomandibular joint dysfunction
Acute Shoulder Strain Deltoid (L)


Plan
Non-con Head CT
Non-con Cervical Spine CT
Non-con Thoracic Spine CT
Non-con Lumbar Spine CT
Non-con Abdomen/Pelvis CT
A/P x-ray of L shoulder

IV hydromorphone 0.5 mg now for pain.

No significant findings on imaging.

Discharge to home. Recommend rest, ice, and OTC pain medications as well as gradual return to normal physical and mental activity. Home health nurse to visit tomorrow. Recommend follow up with PCP in 2-3 days. Follow up with the dentist in 2-3 days for dental fracture. PT/OT as recommended/ordered by PCP. Concussion protocols discussed with the patient. Return to school as tolerated, avoiding significant long periods of reading, tv or other eye strain.

Athletic Training Patient Note

Patient: Jamal (JT) Taylor

Sport: Men’s Basketball (MBB)

Injury location: driving back from home to campus (non-sport related)

Body Part: L SH; head

Full assessment completed 1 day post discharge; visited patient in the hospital emergency room night of accident as well

S: taken to hospital via EMS after roll-over crash; was wearing a seatbelt; airbag deployed; roommate was passenger; reports not remembering entire crash; cannot remember losing consciousness; patient reports headache, jaw pain, and shoulder pain; dull throbbing pain in each area; rates pain 7/10; mild nausea reported; reports brain feels “sluggish”; light makes headache worse; no previous injury like this.

O: BP 142/88; RR: 20; Pulse: 124 BPM; SpO2: 98% on room air (n; Temp: 99.1 F; PEARL normal bilateral; missing tooth (located in patient hand at the hospital); no deformity noted in L shoulder; point tender over anterior and lateral L shoulder

A: Cranial nerve assessment: 2-12 WNL bilateral; equal sensation bilaterally; Glasgow Coma Scale 12/12; 2/4 bilateral radial & dorsalis pedis arterial pulse; no murmurs heard; clear pulmonary auscultation bilaterally; no abdominal rebound tenderness; (+) bite test – deformity noted on lower 1/3 jaw line; (+) nystagmus; 5 word recall score 10/15; SCAT 5 digits score 2/4; Months in reverse order 1/1; no balance or coordination assessments completed at this time; (-) apprehension test (-) sulcus sign; MMT 2/5 abduction, flexion, scaption; external rotation; MMT 4/5 extension, internal rotation; AROM WNL but pain noted

P: follow-up assessments and care plan; appropriate referrals

Audiology Note

Patient Name: Jamal “JT” Taylor
DOB: XX/XX/XX
Date: xx/xx/2023

S: Patient referred for audiologic evaluation by OT. He was alert and cooperative throughout the evaluation and provided his own case history information. He reported that he was recently in a serious automobile accident. He reported a history of hearing loss for many years, and noted that he had difficulty hearing people in the ER and in clinic follow ups since he currently does not wear hearing aids. He stated that he was identified with hearing loss as a child, and was provided with a set of aids which helped him hear better. His most recent set of hearing aids was lost during a recent move and he has been unable to replace them. He reported that he does experience difficulty hearing in his university classes but that he manages by sitting near the front of the class, watching course recordings, and asking his classmates for help. He is required to maintain his GPA for his scholarships, and he noted that his coursework can be exhausting.

He denied recreational or occupational noise exposure. He reported intermittent tinnitus at both ears. He denied a history of vertigo. He denied a history of aural pain, fullness, pressure, or drainage. Family history of hearing loss is unknown because both parents are deceased.

O: Otoscopic examination showed clear ear canals with no abnormalities of either pinna; tympanic membranes were pearly gray with no bulging or retraction; the short process of the malleus and umbo were clearly visible at both ears. Pure tone air and bone conduction testing revealed bilateral mild-to-moderate sensorineural hearing loss. Word recognition ability in quiet appeared excellent (96% AD and 94% AS). Tympanometry measures were WNL at both ears. Ipsilateral acoustic stapedial reflexes were present at 500 and 1000 Hz at both ears and were absent at 2000 and 4000 Hz.

A: Bilateral sensorineural hearing loss. Hearing is impaired to the extent that the patient is likely to have difficulty communicating, particularly in noisy situations and/or when he is feeling tired or unwell. The hearing loss likely has a significant impact on his ability to hear in a classroom setting. Jamal is a candidate for amplification and aural rehabilitation.

P: Amplification evaluation with hearing needs assessment is recommended. Use of a personal amplifier such as a pocket talker as a short-term solution due to difficulty hearing his health care providers is recommended and was discussed. Pt. counseled to keep a written record of instructions given to him by his health care providers, particularly given concerns with hearing these instructions.

Electronically signed by Hannah Milner, Au.D.

Comprehensive Dental Exam
Date: 01/05/23


S: JT Taylor is a 22 year old male who was admitted to the hospital ER a week ago because of a motor vehicle accident where he knocked out a large portion of his maxillary right central incisor (#8) and experienced severe jaw pain while talking. He was referred to the dentist for further evaluation and treatment.

CC: "Sore tooth after an accident."

Med HX: JT Taylor was involved in a car wreck and presented to the Emergency Room with various symptoms. He reported feeling scared and unable to recall the details of the accident. JT mentioned being hooked up to chest wires and experiencing an odd pain in his chest at the time, which he attributed to the seat belt from the crash. He expressed having a headache and difficulty speaking due to an issue with his jaw. During his stay in the ER, JT unexpectedly spat out a large piece of his tooth. He also expressed concerns about his friend, Casey, possibly having a fractured leg in a nearby room.

Allergies: NKDA

Medication HX: JT Taylor is not currently on any medications except for occasional Tylenol for headache and jaw pain.
Social Hx: JT Taylor is single and lives with a college basketball teammate.
Dental Hx: JT Taylor has a dental history of regular checkups with his dentist with previous few restorations because of decay. He complained of a sore tooth and partial tooth loss as a result of the accident and was referred to the dentist for further evaluation a week later.

O:

Clinical Exam:
Extra-Oral Examination:
Facial Swelling: Upon examination, there is noticeable swelling on the lower jaw, with the right side being more swollen than the left. This swelling may be indicative of localized inflammation and trauma.
Bruising: The presence of bruising around the lower jaw, particularly on the right side, suggests external trauma. The pattern of bruising corresponds with the reported impact during the car accident.
Limited Mouth Opening: JT Taylor exhibits significantly limited mouth opening, with the ability to accommodate only approximately one finger. This restricted mouth opening is likely due to pain and discomfort associated with the dental trauma.
Swollen Upper Lips: Swelling is also observed in the upper lip area, which may be attributed to the impact of the accident or the oral trauma itself.
Limited Upper Body Movement: JT reports experiencing pain around the chest area, which appears to restrict his upper body movements. This limitation may be related to the force exerted by the seatbelt during the collision.
Intra-Oral Examination:
Missing Tooth: An intra-oral examination reveals fracture of the maxillary right central incisor (#8). This corresponds with the patient's report of spitting out a large piece of his tooth in the Emergency Room.
Redness Around Mouth Corner: Redness is noted around the corners of the mouth, which may be indicative of irritation or inflammation associated with the oral trauma.
Irregular Patch on Tongue: An irregular patch, measuring approximately 1 cm in size, is identified on the right lateral border of the tongue. This lesion presents with central ulceration and an indurated border. Further evaluation is required to determine the nature of this lesion, as it may be related to the trauma or a separate oral condition.
TMJ Evaluation: Due to JT's report of jaw pain, a comprehensive assessment of the temporomandibular joint (TMJ) is warranted. However, the TMJ evaluation has been deferred at this time due to the patient's discomfort.
Muscle and Sensory Testing: Muscle testing, sensory testing, and joint testing have been postponed during this examination due to the patient's reported pain and limited mouth opening.

A:
Dental trauma with the fracture of the maxillary right central incisor (#8).
Possible temporomandibular joint (TMJ) injury.


Treatment Plan:
Restoration of the fractured portion of the maxillary right central incisor (#8).
Vitality test should be made to ensure that no endodontic procedure is required for maxillary right central incisor (#8) after the trauma. (N.B: A False Positive might result because of the trauma so follow-ups and further vitality tests should be done)
Conduct a thorough clinical evaluation and palpation of the jaw to assess for any signs of injury, dislocation, or misalignment.
Provide appropriate pain management for both dental and chest areas.
Offer emotional support and reassurance.
Refer the patient to an oral and maxillofacial surgeon for further evaluation and potential surgical interventions due to the complexity of the case.
Pain Management: Prescribe over-the-counter analgesics (e.g., Ibuprofen or Acetaminophen) to manage pain and discomfort associated with dental trauma. Consider prescribing stronger pain medication, if necessary, with caution.
Antibiotics: Administer antibiotics (e.g., Amoxicillin or Clindamycin) if there is any concern about open wounds, fractures, or infection risk.
Topical Anesthetics: Recommend the use of topical numbing gels (e.g., Benzocaine) for temporary relief of localized oral pain or irritation.
Radiographic Evaluation: Conduct dental X-rays, including panoramic and periapical radiographs, to assess the integrity of remaining teeth, jaw, and supporting structures. Pay attention to potential fractures or dislocations resulting from the car accident.

Follow-up:
Schedule a prompt follow-up appointment to monitor tooth restoration progress, jaw condition, and additional treatment needs.

Patient Education:
Provide comprehensive education on oral hygiene, dietary restrictions, and adherence to the treatment plan.
Address patient's concerns about his appearance and offer guidance regarding financial assistance options if applicable.

Prognosis:
The prognosis for JT Taylor's dental and jaw condition is dependent on several factors:
His adherence to the prescribed treatment plan and recommendations.
The successful restoration of the broken part of tooth (#8).
The resolution of pain and inflammation associated with the dental trauma.
Proper healing of any potential jaw injuries or TMJ involvement.
Emotional support and management of stress and worries related to the accident and its consequences.
Frequent follow-up evaluations to monitor progress and address any complications or concerns.

Provider: Dr Mohamed Rahhal

Outpatient Occupational Therapy Evaluation

Client Name: Jamal “JT” Taylor
Date of Birth: 10/08/2000
Diagnosis: S06.0 Concussion; M26.60 Temporomandibular joint dysfunction; S46.812A L Deltoid Acute Shoulder Strain
Therapy Diagnosis: F07.81 Postconcussional Syndrome; R68.84 Jaw Pain; M25.512 Pain in left shoulder; R41.844 Executive function deficit; M62.81 Muscle Weakness

Date of Evaluation: 01/05/2023
Referral: Outpatient eval and treat for post-concussive syndrome and L shoulder pain/ROM
Precautions: Soft diet and increased hydration due to restoration of maxillary right central incisor #8.
WB Status: LUE as tolerated

Pain: Pt reports 3/10 pain in LUE at rest and 5/10 pain in LUE with P/AROM at shoulder.

Subjective
Pt is a 22-year-old male who was admitted to the hospital ER on 12/29/22 s/p rollover MVA where he was the restrained driver. Pt sustained a mild TBI, +LOC. Pt reports he lives on campus at Truman State University with a roommate who was the restrained passenger in the accident. He reports his dorm room is on the second floor, and there are 15 stairs with railing to access, and a walk-in shower. Pt is a college basketball athlete and reports Ind with all ADLs and IADLs prior to accident. Pt was discharged from ER to his home with outpatient follow-up.

Since discharge, pt reports experiencing slow processing speed during verbal conversations and with filling out forms or completing classwork. He describes post-concussive symptoms, including photophobia, intermittent diplopia, headache, sleep disturbance with nightmares, and difficulty concentrating. He also reports continued pain 2/2 TMJ dysfunction and L acute shoulder strain with increased pain at rest and with movement. Pt presents with L shoulder sling in place and appears to guard his LUE.

Psychosocial
Pt reports increased anxiety over finances and being able to quickly return to both basketball and his academic coursework. Pt states he experiences nightly nightmares, sometimes 2-3 times per night. He struggles with maintaining a routine and new onset difficulties with time management for school.

Past Medical History: congenital hearing loss - history of wearing bilateral hearing aids, but not currently wearing due to their loss.
Past Surgical History: N/A

Prior Level of Function (PLOF)
ADLs/IADLs: Ind
Driving: Ind
Work: Full-time college student in his senior year; Spanish tutor
Leisure: college basketball athlete; running; cooking

Current Level of Function (CLOF)
Self-feeding: Ind with RUE only; dep for cutting food
UB dressing: Max A
LB dressing: Mod A for underwear, pants, athletic shoes; Ind for don/doff socks
UB bathing: Ind
LB bathing: Ind
Toileting: Ind
Functional mobility: Ind
IADLs: Pt requires assistance for cooking, pouring liquids, opening jars, laundry, folding and putting away clothes, and cleaning. Pt reports difficulty with typing notes for class and completing homework assignments.

ROM
PROM: BUE WFL
AROM: RUE WFL
LUE limited due to pain and guarding
L shoulder flexion: 40 degrees
L shoulder extension: 20 degrees
L shoulder abduction: 25 degrees
L external rotation: 20 degrees
L elbow flex/ext WFL
L wrist and digits WFL

MMT
RUE: 5/5 strength
LUE limited. Pt guarding during testing due to fear of pain.


Sensation
B Light touch: Intact
B Sharp/Dull: Intact
B Stereognosis: Intact

Vision/Perception
Glasses: Pt does not wear glasses
Oculomotor Function: Pt presents with convergence insufficiency resulting in intermittent diplopia, difficulty with near-point reading and writing, and limited visual endurance.
Photophobia: Pt reports sensitivity to light; states he struggles with computer work for more than 10 minutes at a time.

Cognition
Pt is able to follow simple multi-step directions, but struggles when verbal directions are complex in nature. He reports not being able to follow instructor directions in class. Pt demonstrates difficulty with complex working memory and states he was unable to follow a favorite recipe when making dinner recently. Pt also demonstrates decreased safety awareness and difficulty with multi-tasking as evidenced by leaving the oven on after cooking dinner and burning a frying pan after leaving it on the stove after cooking breakfast.

Standardized Assessments
Brief Interview for Mental Status (BIMS): Scored 11/15 or moderately impaired cognition, especially with delayed recall.

Executive Function Performance Test (EFPT): Pt presents with executive function deficits in the initiation of a task, organization when executing the task, judgment & safety when executing the task, and completion of a task. Pt benefits from indirect verbal guidance and gestural guidance during task activities when testing.

Brain Injury Visual Assessment Battery for Adults (BiVABA): Pt presents with deficits in oculomotor function and visual attention, specifically near-point reading and omitting words, distorted print, and needing to view print from the corner of the eye. Visual fields and contrast sensitivity are intact.

Treatment
Pt educated on purpose of skilled OT services and POC. Educated pt and Aunt on post-concussive syndrome and giving the brain time to rest and recover. Issued an Anti Blue Light/Anti Glare Screen Protector for his laptop. Pt instructed on use of recording device to record lectures and in Speech-to-Text for written assignments and computer use. Pt instructed on limiting screen time to 15 minutes and then resting for 15 minutes. Encouraged pt to contact the university’s learning support center for academic accommodations for post-concussive syndrome.

Completed manual heat pack x 20 minutes with skin checks to L shoulder; L shoulder AAROM; LUE wall arcs; scapular mobilizations and AROM for retraction/protraction; isometric exercise for L shoulder flex/ext/int rot/ext rot/add and abd. Pt instructed to discontinue use of sling.

OT Goals
In 4 weeks, pt will be independent with FB dressing.
In 4 weeks, pt will complete a multi-step recipe with Ind and good safety awareness.
In 4 weeks, pt will complete a 30-minute near-point homework assignment without complaints of diplopia or loss of place within the text.
In 4 weeks, pt will complete full L shoulder AROM without complaints of pain.

OT Plan
Pt will be seen for skilled outpatient OT services 2x per week for 4 weeks for ADL/IADL retraining, UE strengthening, work/task accommodation strategies, visual and oculomotor control reeducation, executive function training, and continued post-concussion education.

Referral to audiology for assessment of hearing and hearing aid replacement.

Recommendations
Audiology consult. Pt with past history of congenital hearing loss and hearing aids, but currently does not have aids available.

Consult with university learning support center for academic accommodations for post-concussive syndrome. OT to provide letter of medical necessity as needed for academic accommodations.

PHYSICAL THERAPY

Name: Jamal “JT” Taylor
Age: 22
Occupation: senior university student; waiter
Sex: male
Marital Status: single
Referring HCP: Lee Jackson, DO
Date of discharge from hospital: 12/29/22
Date of PCP referral: 12/30/22
Date of PT evaluation: 01/03/2023

S:
C/C: “I really have a hard time opening my mouth because of pain!”

J.T. is a 22-year old patient who was discharged last week from the Emergency Room following a MVA. He was referred to PT by his primary care physician for further evaluation, specifically for pain in his lower jaw and limited mouth movement.

Patient was conscious and alert X3 in the outpatient clinic when he was first seen by the writer. J.T. expressed his concerns about his best friend who was with him during the car accident. He also expressed concerns about his younger brother who has cerebral palsy. The patient also raised his worries on how his Auntie Rose might take all of this, considering that she stood as their mother after both his parents passed away in a car accident. He is also very worried about his studies and his dreams of being drafted to the NBA. J.T. is in his senior year at Truman State University. Most importantly, he is very worried about his hospital bills.

The patient’s main complaint is a nagging, constant, and stabbing pain around the jaw area, rt>lt. He remembers experiencing the pain immediately after the accident. While he feels that his pain level is getting better because of the medications given to him, he has limited mouth movement that interferes when he talks or drinks water. He mentioned that his pain is localized, although he thinks that the headaches he has been getting lately are coming from the jaw area. Not talking or opening his mouth relieves the pain. At rest, his pain level is rated 7/10 but turns into 10/10 “when it gets really bad.” He denied having a previous injury in his jaw, although he mentioned that he is a “teeth grinder.” During his emergency room visit, he remembered the nurse providing him with a whiteboard, indicating he should use it to communicate with his health care team at his follow up care appointments. During this initial evaluation, the patient has been able to communicate with the writer, although the limited mouth opening was very noticeable. He spoke very softly. He also feels that his hearing has been further affected by his jaw injury; J.T. has been using hearing aids since he was young, though they were lost on a previous basketball roadtrip. He also mentioned experiencing chest pain and suspected that it was probably the force from the seatbelt. The patient is able to ambulate independently with no assistive devices.

He reported that this is the first time that he is seeing a PT and the first time going to an outpatient setting. He mentioned that in all of his years playing sports, he never sustained any injury. At this point, his main PT goal is to be able to open his mouth normally without any pain. He is curious as to how his PT might be able to help him with that. J.T. also provided consent for the involvement of the physical therapist assistant (PTA) in his care, including the implementation of PT interventions that will be prescribed by the writer. He was further informed that he has the right to decline the involvement of the PTA in the delivery of care and that he should immediately inform the writer (PT) about this. The patient was also informed that the writer will be in communication with Dr. Jackson, the referring physician, and inform him of J.T. 's progress. The patient was negative for any jaw fracture or dislocation of the TMJ.

O:
V/S: BP – 120/80mmHg
HR – 65 bpm
RR – 16 cpm
PR – 70 bpm

Ocular inspection:
bruising and swelling noted on lower jaw, rt > left
very limited mouth opening, approximately one finger only (not tested due to +++ pain)
swollen upper lips
limited upper body movement due to pain around chest area

Cranial nerve testing:
I – able to identify smell of hand sanitizer
II – able to read one-line sentence (“I will recover fast and strong!”) scribbled by writer on the white board, distance of 10 ft.
III/IV/VI – able to follow finger movements with eyes (smooth movement noted); PERRLA
V – felt cotton swab bilaterally (forehead, cheek, lower jaw); gross strength not tested due to pain (for masticatory muscles)
VII – sensory: able to distinguish sugar and salt; motor: able to smile, move eyebrows
VIII – decreased hearing reported by patient (PT rubbed his own finger tips close to patient’s ears); reported as “almost nothing”
IX/X – able to say “ah” and symmetric elevation of soft palate noted
XI – not tested due to pain around shoulder area (unable to shrug shoulders)
XII – controlled tongue movement (patient asked to protrude tongue)
Manual Muscle Testing (orofacial muscles) – not tested at this time due to pain
Myotome Testing (upper extremities) – not tested at this time due to pain in the chest and shoulder areas.
Sensory Testing – patient refused testing at this time
Muscle palpation – patient refused testing due to pain
Joint testing (including TMJ) – patient refused testing at this time due to pain

A:
PT Impression: TMJ dysfunction secondary to trauma

Problem lists:
Intractable pain especially in the lower jaw area, relieved by rest and exacerbated by oral movements – affects communication and intake
Generalized body pain as a result of injury, preventing usual level of physical activity – potential for deconditioning
Patient expressing emotional problems as a result of injury (personal and work demands) that warrant constant support from team

P:
Patient will be seen 2X/week (PT and PTA) with the following goals:

Short term:
Educate patient regarding TMJ protection techniques
Gentle passive exercises on TMJ
Educate and instruct patient on specific PT interventions once patient provides consent for full PT evaluation (patient has declined testing at this point)
Liaise with OT/SLP for potential prescription of orthotics and/or techniques to further relieve the jaw pain
Refer patient to counselor for on-going psychological support

Medium term:
Patient will be able to increase mouth opening with limited pain
Continuation of prescribed PT interventions after full evaluation has been completed (patient has declined testing at this point)

PATIENT EDUCATOR - - CERTIFIED HEALTH EDUCATION SPECIALISTS [CHES] CONSULTATION NOTES AND RECOMMENDATIONS:
CHES PROVIDE PATIENT AND FAMILY EDUCATION

PATIENT/FAMILY EDUCATION

FOR MILD TBI

Mild TBI: https://www.cdc.gov/traumaticbraininjury/concussion/index.html
Overview: https://www.biamo.org/about-brain-injury/
Background/Diagnosis/Treatment: https://www.ninds.nih.gov/health-information/disorders/traumatic-brain-injury-tbi
For patients and caregivers: https://www.ninds.nih.gov/health-information/patient-caregiver-education
Provider tools: https://www.cdc.gov/headsup/providers/index.html
Prevention: https://www.biamo.org/prevention/
Community-based Tx: https://www.biausa.org/brain-injury/about-brain-injury/treatment/community-based-treatment
For the general public: Brain Basics, Migraine Trainer® App, Migraine Trainer® Shareable Resources, Mind Your Risks®, NINDS Brain Educational Resources, Know Stroke https://www.ninds.nih.gov/health-information/public-education

FOR GENERAL/RECOVERY

Patient engagement - https://www.ahrq.gov/health-literacy/patient-education/index.html
Orthopedic patient education - https://orthoinfo.aaos.org/
Shoulder - https://www.orthogate.org/patient-education/shoulder https://www.ortho.wustl.edu/content/Education/3556/Patient-Education/Educational-Materials.aspx
Jaw - https://www.verywellhealth.com/jaw-surgery-5082432 https://my.clevelandclinic.org/health/diseases/22014-broken-dislocated-jaw
CHES PROVIDE DISEASE MANAGEMENT EDUCATION AND HEALTH COUNSELING FOR PATIENTS/FAMILY

FOR MILD TBI

Mild TBI Guidelines for adults: https://www.cdc.gov/traumaticbraininjury/mtbi_guideline.html
What to expect post-concussion: https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Patient_Instructions-a.pdf
Mild TBI Management: https://www.cdc.gov/traumaticbraininjury/concussion/getting-better.html
Return to school/play: https://www.cdc.gov/headsup/basics/return_to_sports.html
Health Counseling/Emotional coping: https://www.abct.org/fact-sheets/adult-traumatic-brain-injury-for-mental-health-professionals/; https://www.sciencedirect.com/science/article/abs/pii/S0006322321016413 ; https://www.flintrehab.com/brain-injury-and-mental-health/

FOR GENERAL/RECOVERY
Patient education for shared decision-making:
Use of decision aids
https://www.upmc.com/patients-visitors/shared-decision-making/tools-for-patients/tools-to-help https://decisionaid.ohri.ca/AZinvent.php https://decisionaid.ohri.ca/docs/das/OPDG.pdf https://www.ahrq.gov/patients-consumers/index.html
In-Home Rehab/Therapy – Out-patient Rehab/Therapy: - https://www.verywellhealth.com/physical-therapy-in-your-home-4174973 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8784295/ https://www.frontiersin.org/articles/10.3389/fresc.2021.726410/full https://journals.lww.com/ajpmr/Fulltext/2021/03000/The_Value_and_Role_of_the_Inpatient_Rehabilitation.13.aspx Return to sport/coping

https://www.ncaa.org/sports/2015/2/10/the-psychology-of-sports-injuries.aspx https://www.ncaa.org/sports/2014/11/5/mind-body-and-sport-how-being-injured-affects-mental-health.aspx https://bjsm.bmj.com/content/34/6/436 https://bjsm.bmj.com/content/50/3/145 https://www.acsm.org/news-detail/2021/08/09/the-american-college-of-sports-medicine-statement-on-mental-health-challenges-for-athletes

CHES PROVIDE POLICY/ADVOCACY FOR PATIENTS AND FAMILIES
FOR MILD TBI

Patient support/organizations: https://www.ninds.nih.gov/health-information/support-resources/patient-organizations
Professional Societies: https://www.ninds.nih.gov/health-information/support-resources/professional-societies
Brain Injury Assoc MO: https://www.biamo.org/ ; Services: https://www.biamo.org/services/

CHES CAN COORDINATE CARE AS PATIENT NAVIGATORS
Rural patient navigators: https://www.ruralhealthinfo.org/toolkits/care-coordination/2/care-coordinator-model/patient-navigators
Care coordination: https://www.ahrq.gov/ncepcr/care/coordination.html

Outpatient PT – marketplace - https://www.pt360atl.com/wp-content/uploads/2016/01/Understanding-the-Outpatient-Physical-Therapy-Marketplace-1.pdf Insurance/athletics: https://trumanbulldogs.com/sports/2016/5/19/insurance.aspx ; https://mydss.mo.gov/healthcare/apply ; https://www.healthinsurance.org/states/missouri/ https://dmh.mo.gov/medicaid-eligibility/understanding-types-medicaid https://mydss.mo.gov/apply https://mydss.mo.gov/healthcare Care/low-income: https://carelistings.com/federally-qualified-health-centers/kirksville-mo/northeast-missouri-health-council/5ace887b93efd2372f984e69 ; https://pfh.org/mental-health ; https://adair.lphamo.org/ ; https://mtbh.org/ https://dss.mo.gov/mhd/

BEST NEMO RESOURCE LISTING: nemoresources.org
Home health - https://health.mo.gov/seniors/hcbs/info.php https://health.mo.gov/safety/homecare/pdf/county-served-home-health.pdf https://health.mo.gov/safety/homecare/directory.php Rehabilitation centers/providers - https://www.nermc.com/rehab-services https://npiprofile.com/directory/city/occupational-therapist-in-kirksville-missouri https://npiprofile.com/directory/city/physical-therapist-in-kirksville-missouri

Speech-Language Pathology Note
Date: 1/2/23

S: Pt. is a 22 year-old male who sustained a concussion after being in a MVA on 12/29/22. He also sustained physical trauma to his left shoulder and jaw as a result of the MVA. He was released from the ER the same day. After follow-up with his PCP, the physician recommended SLP evaluation to assess cognitive communication abilities as well as speech and swallowing. Pt. reports he is a college student at Truman State University, where he plays basketball. Chart review revealed a history of mild-moderate hearing loss. A pocket-talker was used during the evaluation to provide amplification. His current complaints include jaw pain following MVA (affecting both the ability to speak and swallow) and difficulty concentrating. He is concerned about being able to keep up with classes once the new semester begins due to his difficulty focusing. He was alert and cooperative at the time of the evaluation.

O: Pt. was 100% oriented to person, place, and situation. He accurately answered 90% of questions related to orientation to time, missing only the current day’s date (by one day). On the Montreal Cognitive Assessment (MoCA), the client scored a 26/30. He exhibited strengths in visuospatial skills, language, naming, and abstraction. His errors were as follows: Concentration task - failed to identify all of the letter “A” exemplars when a string of letters was read by the clinician. Memory - recalled ⅗ words after a delay of 5 minutes. Orientation to time - correctly answered ¾ questions, missing the date. It should be noted that, after completing the MoCA, the pt. recalled “taking something like this before.” After further questioning, it was determined that the athletic trainer at his university gives a baseline screener to all athletes at the start of the year as part of a concussion protocol. Will attempt to contact the trainer to get his baseline results. Pt. also commented that this iteration of the test seemed “harder.”

Oral peripheral examination revealed the following structures and functions to be adequate for speech and swallowing: lips, tongue, hard palate, soft palate, respiration. The pt’s dentition had minor abnormalities, consisting of partial loss of right maxillary central incisor. The pt. reported pain with all requested jaw movements. Jaw range of motion was moderately diminished, likely affecting speech production and chewing for solid foods.

An informal judgment of the pt’s speech intelligibility was completed. Pt. was judged to be 100% intelligible in a quiet environment and when speech context was known. It should be noted that, given the pt’s limited jaw mobility, there was a perception of cul-de-sac resonance, with limited projection of speech. It is likely that, especially in a noisier environment, his intelligibility will decrease due to this decreased volume and lack of complete oral resonance.

Trials of pureed food (pudding) and thin liquids were given to assess swallowing. For one trial, pt. was asked to pretend to “chew” the pudding. Limited rotary mastication was observed. The trial was discontinued after the pt. reported pain. For all other trials and consistencies, the pt. exhibited good bolus formation, good anterior-posterior transfer of bolus, timely pharyngeal swallow, and good laryngeal elevation. No overt signs/symptoms of aspiration were noted.

A: Pt. presents with mild cognitive-communication deficits, consistent with his recent diagnosis of concussion. Deficits were characterized by difficulty with concentration, memory, and orientation to time. In addition, pt. exhibited good speech intelligibility in a quiet environment, but will likely struggle in noisier environments due to limited jaw mobility, resulting in cul-de-sac resonance. Oral preparatory phase of swallowing is currently diminished due to jaw pain. Oral and pharyngeal phases of the swallow were WFL, with no overt signs/symptoms of aspiration.

P: Recommend referral to the Truman State University Speech & Hearing Clinic where pt. should receive services to focus on his mild cognitive-communication deficits. Recommend referral to oral maxillofacial surgeon to assess jaw movement further. If speech and/or swallowing concerns are not improved after that visit, recommend re-assessment by ST to ensure best exercises/compensations based on the surgeon’s recommendations. Until that surgical consult can occur, recommend pt. eat pureed and mechanical soft foods to minimize jaw pain. If pt. requires amplification of his voice due to limited jaw movement for class presentations or other purposes, he can check out an amplification device from the Speech and Hearing Clinic.

Resources

Orientation Recording:

Workshop recordings

Concussion articles

Roles and responsibilities of care providers

Roles and responsibilities of public health/patient educators

Public health education/certified health education specialists (CHES)

Brief IPE-training module with sample case