Clinical Reasoning for Traumatic Brain Injury: A Case Study

This clinical reasoning essay evaluates the preliminary symptoms of a patient with a head injury to identify the disease. The case study focuses on the clinical assessment of the patient based on the background and notes from the patient and his family members. The essay concludes that the patient may suffer due to mild brain injury and it is important to examine specifically after the completion of preliminary assessment processes to pursue the proper treatment procedures.

Clinical Reasoning

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Table of Contents
Introduction:...............................................................................................................................................2
a)Patient situation:......................................................................................................................................2
b) Review information:................................................................................................................................3
c) Process the information:.........................................................................................................................5
Conclusion:..................................................................................................................................................7
References...................................................................................................................................................7

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Introduction:
The present case study has demonstrated the head injury or concussion of an 82 years old dairy
farmer named John Wells who has been to the hospital emergency ward after one day of the
incident of a motorbike accident. The main aim of this clinical reasoning essay is to evaluate the
preliminary symptoms of the patient to identify the disease. After reviewing the entire case
history it can be a case of traumatic brain injury at a mild level as it has several symptoms that
are similar to TBI (traumatic brain injury) (Seunggu Han, 2019). This writing will focus on the
clinical assessment of the patients based on the background and notes from the patient and his
family members.
a)Patient situation:
John Wells is a male 82 years old dairy farmer who became unbalanced from his stationary two
wheels motorbike. Some dizziness was observed after the hitting in his head though there were
no major consequences are observed except the tear in the skin at the time of the accident. But
the dizziness indicates some sort of concussion due to the hitting. According to the medical
sciences, the internal head injury cannot be assessed immediately except for the sign of dizziness
(Neurology, 2019). Headache, confusion, dizziness, nausea, mood swings, thinking impairment
and haziness are the symptoms that are observed in this case.
The reason for these symptoms is the bleeding or tearing the brain due to the tremendous hit on
the head. At the time of the accident, the brain was getting jostled within the skull. There may be
a possibility of primary injuries that are internal blood vessel injuries with bleeding, fractures of
the inner wall of the skull. These may lead to secondary injuries like intracranial pressure,

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cerebral herniation (Henningsen, 2019). But these are all the possibilities and consequences that
may happen if there is a traumatic head injury in the john Wells brain (Medlineplus.gov, 2019).
This can be sure through the primary and secondary clinical survey processes and these are
called ABCDE and AMPLE procedures respectively (Thim et al., 2012). These evaluation
techniques determine the possible disabilities within the patients and the intensity of the head
injury. With the help of effective evaluation, proper treatment can be processed. Because of his
age, there was a chance of future extremities related to the internal brain hemorrhages (WebMD,
2019) and nervous breakdown or paralysis of John wells. Thus it is important to take this matter
as a serious concern so that doctors can start the treatments on an immediate basis. The patient
has been taken into the hospital one day after the accidents happen due to the negligence that
indicates the delayed start of the treatment procedures. Because of his age, it will take more time
than usual to recover from the injury (Medlineplus.gov, 2019). The other skin injuries are not a
serious matter that needs to be concerned because there is only a small tearing and scratches on
the skin of his arms.
b) Review information:
 Patient’s note from the emergency department:
82-year-old male patient John wells were experiencing headaches and confusion immediately
after falling from his motorbike. According to the measurement he is experiencing headaches
with a rate of 4 out of 10. According to his note, John Wells is presently feeling hazy and not
feeling right but he cannot identify the exact physical problems which is a sign of confusion.
John denies any other symptoms like pain, stiffness, reduced rate of neck movement. According

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to the note of Mavis (John’s wife), he did not eat dinner and became quiet which was unusual
when compared in normal situations. There are small tears in his left forearm and little abrasion
to the left elbow.
 Background:
John was returning home from the dairy firm for his morning tea and that time he became
unbalanced and fell on the concrete ground from the motorbike in its stationary condition and the
left side of his head hit the summer ground because he was not wearing a helmet. John resides in
the local rural area with his wife and his son Sam lives in the neighborhood because they believe
independence. John was diagnosed with mild hypertension but he has no family history of
concussion.
 Subjective data:
The subjective data indicates the information gathered from the patient and his family members.
These are considered as the symptoms that are accumulated based on the patient’s and family
member’s observations and feelings. In this case, study, what John and his wife said about the
entire scenario can be considered as the subjective data.
 Objective data:
According to the physical observation by the medical team, John was suffering from the
headache with the intensity of 4 out of 10 with mild hypertension. The result data of primary and
secondary clinical evaluation are also considered as the objective data. Also, small tearing in
forearm and abrasion in the left elbow can be considered as the objective information (Mayo
Clinic, 2019).
 Assessment:

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Based on the subjective and objective data it is important to summarize information according to
the ABCDE and AMPLE procedure. The ABCDE procedure indicates the preliminary test of
airway, breathing, circulation, disability, and exposure. It is an immediate assessment process
applicable to all kinds of critical and injured patients (Thim et al., 2012). The main aim of this
process is to provide the basic assessment to understand the intensity of the injury and after that
preliminary treatment. This process also establishes the common situational awareness in the
adverse situation. This approach is used by emergency technicians and care professionals to
improve the overall treatment procedure. Another assessment process is the AMPLE survey
which indicates the history and physical exams of allergies, medications, past medical history,
last meal, and events (Resus.org.uk, 2019).
c) Process the information:
Based on the information of the present case study it is important to link them with the
assessment process. Information that is collected from the patient and his family members are
summarized below:
1. Mild hypertension
2. A little tear on forearm skin and abrasion in the left elbow
3. Tremendous headache
4. Dizziness
5. Confusion
6. Haziness

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From the above information, it can be concluded that the patient is not suffering from hypoxia
and thus no endotracheal intubation is required. No breathing problem is observed to John wells
but he is suffering from mild hypertension that indicates a little problem in blood circulation in
the head (Healthline, 2019). John is suffering from haziness and he became quite after that
incident that indicates the disability in vision and verbal responses respectively. John cannot
respond properly to the answers and that also indicates the disability in verbal responses. But
significantly there is no problem observed related to the motor responses and that is a positive
sign. There are several other injuries on his skin and left elbow but the intensity of them is quite
lower and it is curable with the help of medication (Osmosis, 2019).
Information that is obtained from the AMPLE survey are as follows:
 No history of chronic disease
 There case history for previous medication
 No part history of head injuries
 The patient has eaten last yesterday and he has no intention to eat
 The patient did not lose his consciousness at the time of the accident or even after that
(Marigorta and Gibson, 2014)
Based on the information it can be concluded that there are no danger or harm related to the
patient and it can be considered as the mild head injuries which are curable by regular
medication and exercises (familydoctor.org, 2019). But for further analysis, this case has been
referred to the special care section where the depth of the injury would be measured with the
help of specific technologies.

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Conclusion:
From the above case study, it can be concluded that the patient may suffer due to mild brain
injury. It is important to examine specifically after the completion of preliminary assessment
processes to pursue the proper treatment procedures. Recovery from a brain injury may take a
long time and the amount of healing is dependent on the intensity of the injury. Thus it is
important to wear a proper helmet to avoid motorcycle accidents.

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References
familydoctor.org. (2019). Head Injuries: Detection, Symptoms, Prevention and Treatment. [online]
Available at: https://familydoctor.org/condition/head-injuries/ [Accessed 17 Aug. 2019].
Healthline. (2019). For Even Mild Hypertension, Lowering Your Blood Pressure Could Sa. [online]
Available at: https://www.healthline.com/health-news/mild-hypertension-lowering-your-blood-
pressure-could-save-your-life-122214 [Accessed 17 Aug. 2019].
Henningsen, P. (2019). Important Info on Brain Injuries Caused by a Motorcycle Accident (Video). [online]
RSH Legal. Available at: https://www.fightingforfairness.com/articles/traumatic-brain-injuries-
motorcycle-accident/ [Accessed 17 Aug. 2019].
Marigorta, U. and Gibson, G. (2014). A simulation study of gene-by-environment interactions in GWAS
implies ample hidden effects. Frontiers in Genetics, 5.
Mayo Clinic. (2019). Traumatic brain injury - Symptoms and causes. [online] Available at:
https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-
20378557 [Accessed 17 Aug. 2019].
Medlineplus.gov. (2019). Head injury - first aid: MedlinePlus Medical Encyclopedia. [online] Available at:
https://medlineplus.gov/ency/article/000028.htm [Accessed 17 Aug. 2019].
Neurology. (2019). Head Injury. [online] Available at:
http://www.columbianeurology.org/neurology/staywell/document.php?id=33918 [Accessed 17 Aug.
2019].
Osmosis. (2019). Clinical Reasoning: Traumatic brain injury - Osmosis Video Library. [online] Available at:
https://www.osmosis.org/learn/Clinical_Reasoning:_Traumatic_brain_injury [Accessed 17 Aug. 2019].
Resus.org.uk. (2019). ABCDE approach. [online] Available at: https://www.resus.org.uk/resuscitation-
guidelines/abcde-approach/ [Accessed 23 Sep. 2019].
Seunggu Han, M. (2019). Traumatic brain injury: Causes, symptoms, and diagnosis. [online] Medical
News Today. Available at: https://www.medicalnewstoday.com/articles/179837.php [Accessed 17 Aug.
2019].
Thim, T., Krarup, Grove, Rohde and Lofgren (2012). Initial assessment and treatment with the Airway,
Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine,
p.117.

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WebMD. (2019). Brain Hemorrhage: Causes, Symptoms, Treatments. [online] Available at:
https://www.webmd.com/brain/brain-hemorrhage-bleeding-causes-symptoms-treatments#1 [Accessed
17 Aug. 2019].