History of present illness:
33yo Hispanic male with ASIA B SCI (C6-C7), sensory incomplete with dislocation and compression injury and concurrent mild TBI, sustained 5 yrs ago s/p mountain biking accident. Underwent spinal decompression and halo fixation. Hospitalized for 1-2 months in acute care. D/c to inpatient rehabilitation where stayed for 9 months. Received outpatient OT/PT services for 2 years.

Past medical/surgical history:
Depression
Halo fixation, spinal decompression

Marital status: Married 11 years.

Primary language: English.

Current level of function: Modified independent - occasional assist for ADLs/IADLs provided by husband or brother. Modified independent for transfers, manual wheelchair propulsion, and use of public transportation.

Employment/work/school: College education. Currently pursuing an undergraduate business degree.

Play/leisure/interests: Enjoys participating in adaptive sports program activities, including wheelchair rugby and cycling. Still follows mountain bike events on television. Plays video games and board games with husband in the evenings.

Environmental factors: Lives with husband in one-story house with 1 STE, ramp at entry. Zero-entry shower with shower curtain, handheld shower head, padded tub transfer bench, grab bars, wash mitts. Padded drop arm commode over toilet with grab bars. Use of u-cuffs for feeding and grooming and padded push gloves for propelling manual ultralightweight wheelchair. Has brother who lives locally and provides assistance 1-2 times a week.

Fall precautions
May ambulate if BP is above 110/70

Midodrine
Oxybutynin
Amitriptyline
Baclofen

X-ray: L femoral neck non-displaced fracture