Review of Notes Documenting Initial Treatment Is Crucial in the Assessment of Acquired Brain Injury

Abstract

TR is a 20-year-old man who was admitted to a neurobehavioral rehabilitation unit due to concerns about cognitive impairment, irritability, and explosive anger episodes. He had experienced a head injury in an assault 2.5 years earlier. The family reported this had been associated with “water on the brain,” he had been in hospital for several days, had briefly been in intensive care unit, and subsequently had significant memory problems. They showed a newspaper clipping of the patient with facial injuries and an airway in place. Psychiatric assessment 2 months after the injury recorded a score of 60 on the Addenbrooke’s Cognitive Assessment Revised and also flashbacks and nightmares related to the assault, hypervigilance, avoidance, emotional blunting, and withdrawal from others. As symptoms did not improve with initial treatment, he had input from a community brain injury rehabilitation team and had already had a 4-month admission to a neurorehabilitation unit. Comprehensive cognitive assessment during this admission demonstrated substantial impairment in verbal and visual memory, executive function (planning, judgment, and task switching), working memory, and speed of processing. The admission ended in an unplanned manner due to aggression toward the staff.