===BEGIN 6/27/90 physical exam, pg 1/3

Physical Examination -- 6 - 27 - 90

*patient is awake, eyes are open
*easily startled to her name or when bedrail fell down
*no respiratory distress, breathing easily
*pupils are equal and reactive
*just short focusing attention, does not track, keeps her head to
the position on the right
*significant amount of tone in the head and neck.
*reflex and voluntary movement of her mouth in a chewing reflex
*T-tube in place & working properly
*severe hypertonicity of all four extremities; plantar flexor
contractures, some shoulder limitation
*"again, tone is quite significant in all four extremities and
difficult to achieve range of motion of the left hip and knee while
she is in a supine position."
*pt is awake
*she does give eye contact to family members
*she will close her eyes to any threatening response around her face
and blink appropriately
*tracking is inconsistent
*no verbal output during this exam but it has been reported by
husband and other family members and therapists over at College
Harbor.
*no voluntary movement on command
*responds to painful stimulation. . . cont on next page . . . [there
is no next page]

===END 6/27/90 physical exam

===Begin Treatment plan pg 2/3

Treatment Plan Review from Mediplex rehab, Bradenton, 1/29/91

*PT 3 X wk due to decreased range of motion in legs.
OT [occupational therapy] modified splints, will look at __ on lap
tray.
*Will check at head rest also

Cognitive/Communication:
*no significant changes.
*Vocalizing when prone in P.T. [physical therapy]
*Occasionally will say "STOP" to nursing during procedures.
*to TR [recreation?] groups. More relaxed to therapists voice, touch
(habituation)

===END Treatment plan

===BEGIN therapy notes, pg 3/3 PDF

3-15-91 Monthly summary ---

Ms. Schiavo was readministered the sensory stimulation assessment
measure on March 13, 1991. The results show a slight increase in a
few response areas.

Terry's [sic] eye-opening responses and motor responses (which
increased two points) are now both her strongest response output
category. However, the vocalization response modality increased two
points also. Terry's tactile response remained her best sensory
input category, as it increased 3 points, the other 4 response
categories remained at about the same level.

These slight increases may be a result of the time change. The
original test was administered at 8:00 a.m. right after she got up
and the second test was given at 4:00 p.m.

Terry's ocular cranial nerve function was assessed and the results
indicated that her pupil sizes were large, she had a very sluggish
response to light, the consensual light reflex was present but she
had an abnormal response to accommodation, tracking, and a blink
reflex. These responses are very similar to last month's
administration.

Overall her general responsivess score increased slightly from 19 to
23, but remains at a __ Level II.

These scores indicate a need for a sensory stimulation program and
this is being developed. In addition, the SS_M will be
readministered in one month. [signed -- a nice caring person]

3 - 28 - 91 Weekly note: Pt. was seen by psych [psychology? rather
than psychiatry, I'm guessing] in the sensory stim program 1 X [one
time], program started 3-25-91. The goal was to increase her
localized responses to sensory modalities. Her best response was to
almond extract (olfactory), otherwise she only responded by opening
her eyes briefly.

Summarizing across the interdisciplinary team results show similar
findings. In addition, the most response increases was to tactile
stimulation. Tx [treatment] plan will be continued. [signed -- nice
person helping Terri 12 yrs ago]

===END

acknowledgements: Free Republic post #569 posted on 11/01/2003

http://www.freerepublic.com/focus/f-news/1011460/posts?page=569#569


Note: This document was on the web but of course it was removed.
http://host85.ipowerweb.com/~friendso/exam.pdf


Save court documentation about Terri. It is being removed from the
internet.