Traumatic Brain Injury: Notes

Jess is a 26 year old female who has been admitted to the large regional hospital you are working in. She was riding with her road cycling group 3/52 ago when she was clipped by a motor vehicle and knocked off her bike at approximately 50km/hr.

Diagnosis: Acceleration / deceleration TBI causing subdural haematoma.

HPI: Nil concerning conditions prior to incident. Initial hypoxia caused blood clot, pt placed on blood thinners and clot was surgically removed. Unstable ICP, being managed daily. Impaired sensation and disequilibrium present.

SHx: Prior to her accident, Jess was a very healthy and active woman, who was studying Mathematics at the local university. She lives with her partner in an inner-city rental which is a double storey townhouse with many narrow stairs. Jess works as a mathematics tutor and has 10 regular clients. Her family lives out of town, but is currently staying close-by while Jess is recovering. Jess has been in critical care for 3/52. She has arisen from her coma and is now lucid.

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