2. Pre-injury Status
Before his injury this 28 year old
male worked full time as an
HVAC technician, installing and
repairing air conditioning units.
He had a substance abuse
problem in the past (strong
opioids), and was in therapy for
a while.
He was married and had no
children. He drove a car and
had an active social life. Apart
from the substance abuse there
were no pre-existing conditions.
3. Present Condition
This patient has not resumed
work because of an aortic
aneurysm 3 months after the
trauma. He also has had 4 leg
operations in last 6 months. He
does not feel his head injury
would stop him from working
again.
His social activities are at a level
of at least one half of that
before the injury. Financial
troubles make it difficult to go
out more often.
4. Present Condition
The patient is able to drive, but
it with considerable effort
because of his legs. He normally
relies on others to transport
him, but could take the bus or
taxi. He has no issue with taking
care of himself, can be left
alone completely and can go
shopping if he wants to.
5. Present Condition
Even though he does not
complain about specific
symptoms and strains that
would be related to the head
injury, he appears very irritable
and actually accuses his wife of
holding back his pain
medication. When pressed, he
admits taking a substantial
amount of oxycodone a day and
being dependent on it. He also
admits to having blurry vision
and occasional headaches.
