Traumatic Brain Injury; Case experience as a model for learning and literature review

摘要

The history, evaluation, treatment and follow-up of a patient with Traumatic Brain Injury (TBI) are presented to illustrate the approach and the difficulties that may be encountered. The literature on TBI is reviewed and a checklist prepared that covers the historical aspects, evaluative procedures, and treatment approaches to TBI. The work with the illustrative case has been compared to the literature review check list to evaluate the completeness of the patient’s care. The result of attempts to obtain outside information, of events prior to the trauma, immediately after the trauma and concurrent with the ongoing treatment also are described. The value of proceeding from a textbook to reviews to recent articles is illustrated. Introduction A single case may be used as a springboard for learning about an illness. Case presentations and case based learning can be used as an opportunity for self learning. Moving from textbook to review articles and then to the current literature can elucidate different aspects of a case from evaluative process to management to recovery to successful discharge and finally to normal premorbid functioning if possible. Using this sequence will not only help in learning more about a particular condition but also consolidate what is already known. Case based learning may be very informative, instructive, educational and stimulating. In this article, a case report of TBI with psychiatric manifestations has been used to illustrate the learning process. TBI is a condition that involves different specialties to coordinate the care of the patient. TBI is a major public health problem and is often accompanied by significant psychiatric manifestations1-3. More than 1.5 million people suffer from TBI annually and more than 50,000 die from it4-7. TBI costs the country more than $56 billion a year6, 8. TBI causes different kinds of psychiatric manifestations which include but are not limited to Cognitive Deficits9a, Mood Disorders9b, Anxiety Disorders9c, Psychosis9d, Apathy9e, 10, Behavioral9f or Dyscontrol Disorders9g, Sexual Dysfunction9h and Sleep Disturbances11. The patient presented in this report was involved in an automobile accident and suffered TBI. This injury has left a huge impact on the life of this patient and serves as a vivid example of how describing the management of such a case can be used for learning purposes by comparing it with what is in the literature. An attempt has also been made to demonstrate from this single case presentation that actual medical practice does not always follow the clinical guidelines. This has been done by comparing the management of this case with the checklist that has been prepared from a review of the literature. Study Method The sequence of the literature review has been from textbook, to review articles to the current literature. A literature search using review articles and the current literature on the subject from 1990-2009 has been conducted and electronic databases including Medline and Ovid have been used for this purpose. The search has been done identifying articles with the two key phrases ‘Psychiatric Manifestations’ and ‘Traumatic Brain Injury’. The articles that have been selected are review articles and current literature on the subject. Patient records were obtained from a university teaching hospital and other hospitals after obtaining consent for the release of information from the patient. The literature search was conducted at the university hospital library. A checklist has been developed which has been used for comparison with the actual management of this case. A review of in-patient and out-patient records from the university hospital and outside has also been done. An attempt has been made to gather data about the patient, including the history of the accident, evaluation during the initial and subsequent hospitalizations, treatment, the reason for referral to psychiatry, the response to treatment and further testing. The results of att