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Section V: Case Study Example

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Case 1: High Biopsychosocial Risk 

  • age 59 veteran male employed in construction
  • fall with left anterior, inferior and medial frontal lobe contusions
  • preinjury drug misuse, ETOH abuse, legal-criminal involvement
  • Chronic back pain

Question: is the above power point slide (from IN System for TBI) for case 1 or 2? Sequentially was before the information below.

Case 2: Significant Variability in Recovery 

  • 18 year old female in found down along the side of road with TBI and Glasgow Coma Scale = 6/7
  • Bilateral frontal subarachnoid hemorrhages, left parietal scalp hematoma, respiratory insufficiency
  • Left hemiplegia, significant attention and executive function impairment 
  • Pre-injury anxiety and learning disability

Case 3: Sometimes it is easier to tell an avatar

  • 36 year old married male working as a carpenter
  • Motor cycle crash with TBI and bilateral temporal and orbital fractures 1 month before entering RF
  • Pre-injury history of opioid misuse and depression
  • In Resource Facilitation intake, twice denied depression
  • On PHQ-9, endorsed “Thoughts that you would be better off dead, or hurting yourself.”
  • Triggered Resource Facilitation response and got participant into treatment

Case 4: Getting worse

  • 30 year old man with 16 years of education working as a server
  • Preinjury history of DUI and felony theft
  • Fell out of a second story window and may have been using ETOH and Xanax at party beforehand 
  • Initial risk stratification was low risk
  • Risk Stratification changed to medium (yellow) with more intense RF follow-up, case conferences and directed to PCP

Should we add Judy’s/Lance color coded matrix of rectangles (with a brief explanation)? I think it summarizes this topic well.

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