Based on the above findings, provisional
ideas begin to develop. In the course of the time
based evaluation these may change. We have found that
a multi-axial schema is critical taking into account
an amplification of DSM 4 psychiatrically and an equivalent
schema neurologically. These are reflected below under
two major sections - neurologic neuropsychiatric.
This example is of a prototype patient with CHIT.
The complexity of all these elements in this way can
be perceived.
Evaluation Based on the above findings,
the following provisional ideas seem appropriate.
| |
PREDOMINANT DIAGNOSIS |
Closed head injury of transient kind
(CHIT)
Mixed elements:
Post traumatic syndrome, Post concussional syndrome
Possible contrecoup injury with frontal lobe features
(residual focal)
Secondary sexual dysfunction BR> Secondary Pain syndrome predominantly hips
Tinnitus chronically
Abnormal EEG with right lateral temporal structural
abnormality
Headache and dizziness both improving
Obesity |
| |
NEUROLOGIC LABEL: |
|
| 1n |
Neurologic overview |
CHIT with PTS, PCS, Focal syndrome |
| 1s |
Seizure Classification |
possible minor temporal lobe features:
structural on EEG and clinically correlates with
tinnitus? and headache? |
| 1m |
Movement disorder |
no evidence at this time |
| 1s |
Dyssomnia |
intermittent initial insomnia (mild,
secondary to psychological elements) |
| 1h |
Higher cortical elements |
high functioning individual previously;
now Significant organizational - integration impairment
with frontal lobe elements |
| 1p |
Perceptual distortions |
tinnitus - chronic persistent since
accident. |
| 1h |
Pain syndrome |
headaches when tired |
| 1 g |
General neurologic |
CHIT |
| 1pn |
RELEVANT MEDICAL CONDITIONS |
no evidence at this time |
| 1fn |
Family history |
No neurologic family history |
| 2 l |
Learning style |
No evidence of pre-existing learning
disability |
| 2n |
Premorbid Intelligence: |
Normal range. |
| 3p |
Physical condition |
As per examination, main complaints,
social history |
| 3n |
Links of Neurologic events to presentation |
Probably significant. Dynamically
different coping styles exist. Organically different
compensations for deficits occur. |
| 3 c |
Cerebral Localization |
Temporolimbic phenomena not triggered
or mobilized by hallucinogen or stimulant use |
| 4 |
Special investigations |
as listed above |
| 4e |
Electroencephalographic |
sleep and wake EEG 1993 slightly
abnormal with bitemporal spiking ambulatory EEG
right lateral temporal |
| 4n |
Neuroradiologic |
tests as above MRI 1995 apparently
normal |
| |
Other test features: |
apparently normal blood tests |
| 5n |
Course: |
|
| |
Deteriorating or not |
Non-deteriorating |
| |
Chronicity degree |
Not chronic |
| 6n |
Neuropharmacologic Response |
Carbamazepine has helped the explosive
anger but not assisted with the amotivation and
dysexecutive phenomena |
| |
Compliance |
By history, expected to be reasonable |
| 7n |
Neurologic onset age |
since head injury on 4/7/97 |
| |
NEUROPSYCHIATRIC FRAMEWORK: |
|
| |
Descriptive Psychopathology: |
atypical depression and anxiety confusional
episodes |
| 1 fp |
Family history |
family history negative except for
one aunt |
| 2 a |
Addictive disorder |
no evidence of alcoholism or drug
dependency or abuse |
| 2p |
Personality Elements: |
No relevant characterologic deficits.
Anankastic personality features accentuated post-injury
possibly as coping mechanism |
| 3p |
Relevant Physical disorders: |
conditions above are major components
to current psychopathologic manifestations |
| |
Symptomatic relevance: |
major components to current psychopathologic
manifestations
|
| |
Relatedness to illness: |
significant |
| 4p |
Psychosocial components: |
&&&&& &&&&&&&&&
|
| |
Family support |
reasonable |
| |
Patient Strengths |
self-perceived: "trying to get
better" |
| |
Predisposing factors: |
Constitutional diathesis. Environmental
experience. Aggravating cerebral trauma |
| |
Precipitating stressors: |
No significant new stressors. Chronic
difficulties linked with impaired function |
| |
Perpetuating factors: |
Predisposing elements |
| |
Problem areas |
listed above |
| 5p |
Functionality: |
&&&& &&&&&&&&&& |
| |
Maximum expected in future: |
limited |
| |
Highest functionality before insult: |
reasonable: normal days work |
| |
Functionality currently: |
limited by deficits and unable to
work though does daily chor$ |
| 6p |
Psychopharmacologic: |
|
| |
Psychopharmacologic Responsiveness: |
as listed above: buspirone has helped
irritability and concentration |
| |
Psychopharmacologic Compliance: |
historically reasonable |
| 7p |
Age of onset of major psychopathology: |
since head injury on 4/7/97 |
