Case Study 1: Patient With Traumatic Brain Injury

EXAMINATION

History

• Demographic Information:

  Patient is a 41-year-old, Filipino-Caucasian man. He is English speaking and right-hand dominant. He was admitted to the adult brain injury service for inpatient rehabilitation after a motorcycle accident.

• Social History:

  Patient is an ex-Marine; he has one son and is divorced from his wife. He lives with his fiancée in a single-story home. His fiancée has three children who live with them, ages 12, 13, and 15. The patient’s fiancée does not work outside of the home but is responsible for the cooking, laundry, cleaning, and upkeep of the home, as well as taking care of the children.

• Employment:

  Patient worked as an inspector for a fire safety company. His job involved driving to various locations where he inspected and tested various fire safety equipment (such as fire alarms, fire extinguishers, and so forth), which involved a moderate amount of physical activity.

• Living Environment:

  Patient resides in a single-story home, which is split level, with one step to enter the home’s main living room area. There are three steps to enter the home, with no handrails or ramp in place.

• General Health Status:

  Patient is medically stable and able to participate in a rehabilitation program. Before this injury, patient was believed to be in good general health.

• Social and Health Habits:

  Patient enjoys playing basketball and softball with his friends. Before injury, he was not involved in a formal exercise program but remained active playing sports, spending time with the children, and through work activities. Patient states his favorite activities are riding motorcycles and “hanging out at the bars.” Although it is unclear how much, the patient has a history of alcohol use; his use of other drugs is unknown.

• Medical/Surgical History:

  Medical history is unknown because of incomplete medical records from previous facility. Patient is agitated and unable to consistently and appropriately answer questions. Surgical history before this injury is unknown.

• History of Present Illness:

  This is a 41-year-old male, status post–motorcycle accident while intoxicated on June 28. The patient was reportedly found approximately 70 feet (21 m) from the site of impact. He was brought in by ambulance to an acute hospital with a Glasgow Coma Scale (GCS) score of 1-1-1; blood pressure was 90 systolic (diastolic not documented), with a heart rate of 160 beats per minute and an oxygen saturation measurement (SpO₂) of 80% using pulse oximetry. Owing to the low GCS score and decreased oxygenation, the patient was immediately intubated and ventilated. He was noted to have 2-mm pupils bilaterally and was nonreactive, with motor function evident on only the left side. There were multiple skin abrasions on the right shoulder, chest, and hip. Upon admission to the acute facility, the patient underwent computed tomography (CT) scan and was diagnosed with the following: flailed chest with multiple rib fractures, lung contusions, pneumothorax, contusion and laceration of the right lobe of the liver with hemoperitoneum (presence ...