3.1 Problem List

A 53-year old male fell down stairs while intoxicated.  He had a history of chronic alcoholism, low back pain, poor relationship history, poor social supports, and was unemployed at the time of accident.  His injuries includes a basal skull fracture, left fronto-temporo-parietal SDH (drain via burr hole, bifrontal hemorrhagic ICH).  He was admitted to rehabilitation 7 days post injury.

The patient is ambulatory, although he has been seen to stagger occasionally and is somewhat neglectful on the right side.  Speech is intelligible though slurred and loud (he sounds drunk!).  He makes inappropriate comments to staff, particularly sexually inappropriate remarks.  When agitated he tends to swear loudly, and gesture aggressively (waved his fist around).  He is perseverative regarding a number of things:  Making phone calls, leaving the unit, going for a smoke, going home, people stealing his belongings, etc.

He has an attendant who will follow him but not engage him as he has hit staff previously.  He is not safe to be restrained in a wheelchair as he will stand still tied into the wheelchair or he will tip the chair.  He also cannot be restrained in bed as he will try to escape, become entangled, or become more agitated and kick staff as they are attempting to apply the restraint.  He lacks insight into his behavior and deficits and does not understand why we are “keeping his locked up in this jail”.

Other staff, patients and families are afraid of him and avoid him.  Other brain injured patients are aroused by him and have become violent/aggressive due to his behaviour.  He frequently refuses all of his medications so he is not consistently on any pharmacological agents to manage his agitation.

Create a problem list:
  • Intoxicated
  • Basal skull fracture
  • Left fronto-temporo-parietal SDH (drain via burr hole, bifrontal hemorrhagic ICH
  • Speech (Sounds drunk!)
  • Agitated, sexually inappropriate
  • Perseverative on multiple things
  •  Not safe to be restrained
  • Lacks insight into his behaviour and deficits
  •  Violent/aggressive
  • Refuses all of his medications