Pre-injury StatusBefore his injury this 28 year oldmale worked full time as anHVAC technician, installing andrepairing air conditioning units.He had a substance abuseproblem in the past (strongopioids), and was in therapy fora while.He was married and had nochildren. He drove a car andhad an active social life. Apartfrom the substance abuse therewere no pre-existing conditions.
Present ConditionThis patient has not resumedwork because of an aorticaneurysm 3 months after thetrauma. He also has had 4 legoperations in last 6 months. Hedoes not feel his head injurywould stop him from workingagain.His social activities are at a levelof at least one half of thatbefore the injury. Financialtroubles make it difficult to goout more often.
Present ConditionThe patient is able to drive, butit with considerable effortbecause of his legs. He normallyrelies on others to transporthim, but could take the bus ortaxi. He has no issue with takingcare of himself, can be leftalone completely and can goshopping if he wants to.
Present ConditionEven though he does notcomplain about specificsymptoms and strains thatwould be related to the headinjury, he appears very irritableand actually accuses his wife ofholding back his painmedication. When pressed, headmits taking a substantialamount of oxycodone a day andbeing dependent on it. He alsoadmits to having blurry visionand occasional headaches.