Once out of the water, her friends noticed that that she was bleeding freely on the side of ere head where she struck the side of the pool.
Mary was rushed to a hospital ICC where PET scans were given which indicated bruising and hemorrhaging on the frontal lobes tissues. Additional injuries were suspected as well. She was placed on precautionary life support. After two hours in the CICS, she woke up moaning incoherently and moving restlessly. She was examined by a neurologist and responded to strongly present verbal and tactile stimuli; she opened her eyes briefly, looked at the nurse and moved her finger upon request.
Her level of responsiveness gradually began to improve overnight.
The following morning she was awake and could recognize and weakly verbally respond to her parents. After one week in the hospital, Mary was released to her parents by hospital Staff who advised her parents to gradually allow her to increase her activity level at home. At home, Mary continued to recover with few apparent problems. At the neurological follow up one week later, Mary was examined and then cleared to return home and continue to recover until she felt well enough to return to high school.
Mary stayed at home for two more weeks and then asked her parents if she could return to school to finish out the year. Upon Mar’s return to school, problems emerged.
She came home the first day and complained that she didn’t want to go back the next day. She stated to her parents that she couldn’t keep up in class, couldn’t concentrate, and couldn’t take notes as fast as she used to. She complained she was having problems remembering the words and instructions of her teacher.
She found that when the class was given a writing assignment in English, all the other students finished on time but she hadn’t even finished the introductory paragraph. She further complained of feeling worn out at the end of the day, and didn’t want to see her friends. She only wanted stay in her room for the rest of the day.
As she walked to her bedroom, she said to her parents, “ I’m not going to school tomorrow, just can’t do it! ” and slammed the door. She stayed in her room for the rest of the afternoon and had to be called several times before she would come to dinner.
The next day her parents asked the hospital for testing and assessment and the hospital staff recommended Mary to our practice. TUB Diagnostics and Criteria Mar’s situation is unfortunate.
She has obviously suffered a traumatic brain injury. “ The term traumatic brain injury (TUB) refers to injuries to the brain that re caused by some form of traumatic impact. Traumatic brain injuries usually are caused by a blow to the head, violent shaking or penetration of the brain tissue” (All About TUB, 2012, Para 1).
The symptoms of a TUB include headache, dizziness, loss of consciousness, blurred vision, confusion, memory loss, seizures, paralysis, and coma.
However, some T IBIS are so severe that they can be fatal. Brain characteristics and functions that can be affected by a TUB include “ consciousness, speech and language, memory, mobility, personality and others” (All About TUB, 2012, Para). The ADSM-IV-TRW does not roved diagnoses specifically for TUB. However, it offers diagnoses of Cognitive Disorder, NO’S (not otherwise specified), Dementia secondary to TUB, and Amnesties Disorder which are secondary to T Bal.
In Marry case, she was unconscious and had to be pulled out of the water suggesting she had at the very least suffered a concussion.
This disorder is classified under the Postindustrial Disorders in the ADSM-IV-TRW as follows: A. A history of head trauma that has caused significant cerebral concussion. Note: The manifestations of concussion include loss of consciousness, postgraduates amnesia, and less commonly, postgraduates onset of seizures. The specific method of defining this criterion needs to be established by further research. B.
Evidence from neurophysiology testing or quantified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory (learning or recall of information).
C. Three (or more) of the following occur shortly after the trauma and last at least 3 months: 1 . Becoming fatigued easily; 2. Disordered sleep; 3.
Headache; 4. Vertigo or dizziness; 5. Irritability or aggression on little r no provocation; 6. Anxiety, depression, or affective instability; 7. Changes in personality (e. G.
, social or sexual inappropriateness); 8.
Apathy Or lack of spontaneity. D. The symptoms in criteria B and C have their onset following head trauma or else represent a substantial worsening of preexisting symptoms. E. The disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning.
In school-age children, the impairment may be manifested by a significant worsening in school or academic performance dating from the trauma. F. The symptoms do not meet criteria for Dementia Due to Head Trauma and are not better accounted for by another mental disorder (e. .
, Amnesties Disorder Due to Head Trauma, Personality Change Due to Head Trauma) (Ontario Memorandum Foundation, p. 3). A TUB can be an open head injury or a closed head injury. “ Open head injuries are injuries in which the skull has been fractured or the membranes surrounding the brain (durra mater) have been breached” (All About TUB, 2012, Para 5).
These types of injuries are very serious and may require surgery to extract pieces of the fractured skull and implant synthetic pieces. Closed head injuries, on the other hand, do not break the skull and are typically caused by blows to the head.
Both open and closed head injuries can cause mild to severe brain damage (All About TUB, 2012). Diagnostic Imaging Scans Since the PET scan administered to Mary indicated bruising and hemorrhaging on the frontal lobes tissues, it can be assumed that she suffered a closed head injury (there are no indications that she needed any surgical repair which would have suggested an open head injury) (All About TUB, 2012). “ Positron emission tomography (PET) is an imaging test that uses a addictive substance (called a tracer) to kick for disease in the body.
Unlike magnetic resonance imaging (M RI) and computed tomography (CT) scans, which reveal the structure of organs, a PET scan shows how the organs and tissues are functioning’ (Tool, 201 0, Para 1). PET scans use a small amount of a radioactive substance injected into a vein which travels through the blood and collects in organs or tissues. The PET machine detects energy given off by the radioactive substance and converts it into 3-dimensional pictures. The images are sent to a computer, where they are displayed on a monitor or the physician to read.
The test takes about 30 minutes (Tool, 2010). An fem.
(Functional magnetic resonance imaging) is a technique for measuring brain activity. This technique detects “ the changes in blood oxygenation and flow that occur in response to neural activity -? when a brain area is more active it consumes more oxygen and to meet this increased demand blood flow increases to the active area” (Devoid, H. , 2012, Para 1). The fem. can identify the parts of the brain are involved in a particular mental process (Devoid, 2012). According to Leak et al.
The fem. can be a great tool for investigating clinical applications of motor and language mapping along with “ psychological processes such as time and perception”, semantic processing, response inhibition, emotional processing, compensatory processing, etc. Given Marry difficulties in school post injury, this scan may be beneficial in identifying any of the above if present. Tests and Assessments Depending on the cause and severity of the brain injury, brain damage can be mild, moderate, or severe.
To determine which level Mary has suffered, tests need to be administered. One such test is the The Glasgow Come Scale.
This test is “ based on a 15 point scale for estimating and categorizing the outcomes of brain injury on the basis of overall social capability or dependence on others” (Transubstantiation’s. Com, 2001, Para 2). The test measures motor response, verbal response and eye opening response in the following manner: Eye Opening Response ; Spontaneous–open with blinking at baseline 4 points ; TO verbal stimuli, command, speech 3 points ; To pain only (not applied to face) 2 points ; No response 1 point Verbal Response ; Oriented 5 points ; Confused conversation, but able to answer questions 4 points ;
Inappropriate words 3 points ; Incomprehensible speech 2 points Motor Response ; Obeys commands for movement 6 points ; Purposeful movement to painful stimulus 5 points ; Withdraws in response to pain 4 points ; Flexing in response to pain (decorticate posturing) 3 points ; Extension response in response to pain (decelerate posturing) 2 points ; No response 1 point Categorization: Coma: No eye opening, no ability to follow commands, no word overvaluations (3-8) Head Injury Classification: Severe Head Injury-ACS score of 8 or less Moderate Head Injury-ACS score of 9 to 12 Mild Head Injury- ACS score of 13 to 15 (CDC, 2003).
It is imperative that we keep in mind that the results of this test may vary from the initial injury and hours or days post.
It is possible a patient scores poorly at first and improves later on. One can imagine that Mary would fall in that category of patients as she was originally unconscious (immediately following the blow) and presumably scored poor on this test. However, two hours later, she responded well when she was examined by a neurologist: she responded to strongly present verbal and improve overnight and the following morning she was awake and could agonize and weakly verbally respond to her parents.
Thus, administering the Glasgow Come Scale one day post injury would presumably produce much improved results. Other tests that can be administered to Mary which use the Pre-Morbid measures of functioning are the NAIRA Test and the Heckler Adult Intelligence Scale (WAIS) test These tests will be beneficial in comparing and contrasting her previous intellectual abilities with current, post-injury abilities.
As indicated in the summary, Mary has shown a drastic decline in her academic performance possibly as a result of her TUB. The tests ascribed below should be able to identify the problem and allow for treatment recommendations. The North American Adult Reading Test (NAIRA) is a quickly administered index that is widely used to estimate verbal intellectual ability” (INCUBI, ND. , Para 1). This test is used to measure verbal intelligence (INCUBI, ND).
The NAIRA consists of a 61 word list designed for US and Canadian residents (Leak, et al. , 2004). The test takers are asked to pronounce these words. “ Each incorrectly pronounced word is counted as one error, score range is from O to 60, with O indicating no pronunciation errors and 60 indicating pronunciation errors on all items” (NEURON ALEX, ND, Para 1).
The only issue with administering this test to Mary is that she is Latino and English may not be her primary language which may hinder the scores of the test. Having said this, there is not enough information as to whether or not English is her primary or secondary language, thus this option should remain in consideration.
The Heckler Adult Intelligence Scale (WAIS) IV test was developed to provide the most advanced measure of cognitive ability (Heckler, 2012). It IS a paper and pencil test that takes between 60 to 0 minutes to complete.
This test is a newer version of the original WAIS which was enhanced in 2008 and is includes the following subtest: Verbal Comprehension, Perceptual Reasoning, Working Memory, and Processing speed (Hollyhock et al. , 2011).
Mary should be referred to take this test to examine her current strengths and weaknesses in the above mentioned abilities. In addition to these tests, previous school records should be collected from Mar’s school, such as the No Child Left Behind Testing records. These records will be crucial in providing a clear picture of the agree to Mar’s degree of brain damage.
For example, if Mary previously scored high on these tests (which, according to the summary, she most likely did) and she now scores poorly, it will be safe to assume that the TUB is responsible for this decline. It will also aid in the treatment recommendation.
To assess Marry cognitive speed, the following tests have been chosen: Trails A & B, Digit-Symbol Test, and PASTA test. She indicated that she couldn’t take notes as fast as she used to, thus these tests are vital in determining a diagnoses and cause.
The Trail Making test is a neurophysiology test in which participants must connect-the-dots (traverse between items) in a specified order. In Test A these items are numbers and the order is determined by increasing magnitude. In Test B these items are both numbers and letters (1 etc. ) and the order is determined by a combination of increasing numbers AND letters (e.
G. , 1 A 2 B 3 C.. ) requiring participants to alternate between letters and numbers (Cognitive Atlas, ND).
“ The Symbol Digit Modalities Test (SDTV) detects cognitive impairment in less than 5 minutes” (Western Psychological Services, ND).
The test detects the presence f brain damage as well as “ changes in cognitive functioning over time and in response to treatment” (Western Psychological Services, ND, Para 2). The SDTV is a “ simple substitution task that normal children and adults can easily perform. Using a reference key, the examine has 90 seconds to pair specific numbers with given geometric figures. Responses can be written or oral, and for either response mode, administration time is just 5 minutes” (Western Psychological Services, ND, Para 3).
The test is used to assess individuals with head injuries, strokes, Alchemist’s disease, learning disorders, etc.
Western Psychological Services, ND). “ The PASTA is a measure of cognitive function that assesses auditory information processing speed and flexibility, as well as calculation ability’ (National MS Society, ND, Para 1). The PASTA is administered by using audio cassette tape or compact disk to “ ensure standardization in the rate of stimulus presentation. Single digits are presented every 3 seconds and the patient must add each new digit to the one immediately prior to it” (National MS Society, ND. , Para 1).
Administration time is approximately 10-15 minutes including practice sessions.
The score is he combined correct answers out of 60 possible (National MS Society, ND). As mentioned above, these tests will measure Mar’s cognitive speed. Given the facts that Mary was an excellent student, one can assume that results from such prior tests, if any, would have indicated high scores. Once again, the current scores bothers tests will provide an explanation of her current cognitive speed, but also will allow for a comparison to her previous abilities. Recommendations and prognosis Suffering a TUB can be devastating.
As evident by the summary of the case study, Mays life has taken a dramatic turn for the worse.
She is definitely in need of ongoing treatment to deal with the symptoms she is experiencing post TUB which may indicate PETS, depression, possible learning disabilities and more. However, Mary needs to be closely monitored and provided with ongoing treatment that corresponds to her diagnoses. It is possible that medication can assist her in coping with the depression and PETS symptoms (if those are identified). Further, cognitive and behavioral therapy may be options Mary can seek. Overall, Mar’s prognosis looks somewhat promising.
She scored well on the neurological test hours after the injury.
She was able to respond to nomads and recognized her parents. This suggests that the TUB is not severe. Mary and her doctors need to establish which functions can be restored and which will need to be re-learned. She may find exercises in cognitive skills such as arithmetic problems, concentration improvement, logic enhancing puzzles, etc.
