Brain Injury Medicine Examination Study Guide

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A patient opens her eyes spontaneously and intermittently tracks a mirror across the visual field. Repeat standardized testing to establish whether tracking is reproducible and purposeful before classifying her condition solely from spontaneous eye opening.

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A patient follows commands during morning therapy but appears unresponsive after a sedating procedure. Review medication timing, assess medical stability, and repeat the same standardized consciousness assessment during an adequately alert period before changing the diagnosis.

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A 30-year-old remains minimally conscious six weeks after severe TBI despite correction of sedation and infection. Discuss amantadine within a monitored rehabilitation plan because the injury type, age, timing, and diagnosis match the evidence-supported population.

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A patient with acquired brain injury eats quietly but develops recurrent respiratory infections and wet vocal quality after drinking. Instrumental swallowing assessment is indicated to evaluate airway protection. On videofluoroscopy, material contacting the true vocal folds without passing below them is penetration. Material passing below the folds without an attempt to eject it demonstrates silent aspiration.

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A medically fragile patient cannot readily travel to radiology, and the team needs to examine secretion management and pharyngeal residue. Consider bedside FEES while recognizing that an oral-phase transit question may require a different assessment.

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Thickened drinks reduce airway invasion during assessment, but a patient subsequently drinks very little. Reassess hydration, residue, acceptance, and alternative strategies with the swallowing team rather than judging success from the instrumental image alone.

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A patient without seizures reaches day eight after moderate–severe TBI while still receiving prophylactic medication. Review whether a separate treatment indication exists rather than automatically continuing medication throughout the remainder of the rehabilitation admission.

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A patient has a documented focal seizure three weeks after TBI. Evaluate the seizure and its provoking factors and formulate a treatment plan; the seven-day preventive recommendation does not justify stopping treatment for this new event.

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An elbow extends much farther during slow movement than during rapid stretch. This dynamic difference supports a spastic component and helps estimate potential benefit from tone treatment before deciding that the entire limitation is fixed.

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Finger flexor overactivity prevents palm cleaning despite useful proximal arm movement. Define a hygiene goal, identify contributing muscles, and consider focal treatment with stretching and caregiver training rather than broadly suppressing tone throughout the body.

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A patient relies on leg stiffness during assisted transfers but has painful ankle inversion. Observe the transfer and target the problematic pattern while preserving necessary support, then reassess both pain and transfer performance after treatment.

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A patient's previously stable tone increases during a week of constipation and uncomfortable seating. Correct those contributors and reassess the distribution before escalating medication that could reduce alertness during cognitive and mobility therapy sessions.

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A patient speaks indistinctly but accurately follows complex instructions and writes coherent answers. Assess motor speech while preserving access to written communication instead of assuming that reduced intelligibility establishes impaired language comprehension or global cognition.

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A bilingual patient performs poorly on English naming but previously used another language for most daily activities. Obtain a language history and assess relevant languages with appropriate support before attributing the English result entirely to injury.

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A patient struggles to explain a discharge preference verbally. Present two pictured destinations, add written keywords, allow pointing, and verify the selected meaning through a second accessible question before documenting the patient's expressed preference accurately.

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A patient develops brief spinning when rolling in bed after TBI. Dix-Hallpike testing produces torsional, upbeating nystagmus on one side. Select a corresponding canalith repositioning maneuver once cervical and positioning precautions have been addressed.

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A patient reports classic bed-turning vertigo but remains under cervical movement restrictions after trauma. Establish spinal precautions and use an appropriately adapted assessment pathway instead of performing standard neck extension and rotation during the bedside examination.

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A patient has continuous dizziness, new limb incoordination, and no characteristic response during positional testing. Evaluate a broader neurological cause promptly instead of interpreting the history of head trauma as sufficient evidence for posterior-canal BPPV.

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A patient remembers conversations but repeatedly misses scheduled therapy. Practise entering appointments into a simple reminder system and responding to its alerts during the actual daily routine, with support adjusted to the patient's learning capacity.

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A patient repeatedly enters an incorrect code while learning to unlock a medication cabinet. Provide the correct sequence with immediate cues and structured practice, then reduce prompts only when accurate performance becomes stable in context.

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A patient improves on word-list exercises but still leaves essential items at home. Practise a departure checklist beside the door, rehearse it before real outings, and track whether the patient consistently leaves with needed belongings.

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A patient loses focus late each morning after taking a sedating medication and sleeping poorly. Review those contributors and compare attention across the day before concluding that all observed inattention reflects a fixed injury-related deficit.

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A patient completes a dressing sequence in a quiet room but stops when several staff speak nearby. Begin with one speaker and reduced background noise, then introduce controlled distractions only after the sequence is consistently successful.

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A patient answers accurately after a pause, but staff repeat questions before the response begins. Use a single clear instruction and adequate waiting time, then check understanding rather than increasing the speed or number of prompts.

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A patient can describe preparing lunch but repeatedly abandons it midway. Practise a written goal, ordered steps, scheduled checks, and review of the completed meal instead of simply asking the patient to explain the recipe again.

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A patient predicts error-free completion of a shopping task but omits several items. Review the prediction beside the actual checklist, identify where monitoring failed, and practise a checking strategy during the next supported shopping activity.

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A patient performs well during one-to-one testing but repeatedly leaves cooking tasks unfinished at home. Observe a realistic multistep task and examine initiation and monitoring demands before treating the formal score as proof of independent functioning.

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A patient correctly names the hospital but repeatedly forgets visitors and attempts to leave for appointments already completed. Continue serial PTA assessment and supervision rather than declaring recovery solely because orientation questions were answered correctly that morning.

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A confused patient becomes distressed during repeated visits from large groups. Limit simultaneous visitors, keep explanations brief and consistent, and provide a predictable supervised routine while continuing tolerable activities and serial assessment of recovery from PTA.

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A patient becomes agitated each afternoon during uncomfortable transfers and a crowded therapy session. Assess pain and transfer technique, reduce competing stimulation, and track the response before interpreting the pattern as an indication for routine sedating medication.

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A patient reports three weeks of sadness, loss of enjoyment, guilt, and worsening withdrawal after previously engaging in rehabilitation. Assess a depressive syndrome and suicide risk instead of explaining the change solely as expected post-injury fatigue.

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A patient has low mood, marked fatigue, and reduced participation several months after injury. Assess depressive symptoms while reviewing sleep, medication exposure, and possible endocrine features, rather than assuming either a purely psychiatric or purely neurological cause.

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A patient begins treatment for depression but still needs reminders to attend sessions. Track mood, safety, side effects, and daily engagement while adapting communication and reminders, rather than treating missed appointments as definitive evidence of treatment failure.

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A patient with stable post-injury cognitive symptoms meets criteria for PTSD and wants psychotherapy. Discuss prolonged exposure, cognitive processing therapy, and EMDR, including how treatment demands can be accommodated, instead of offering only supportive visits indefinitely.

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A medically cleared passenger avoids every car journey because reminders of the collision trigger fear. Discuss structured PTSD treatment targeting avoidance while confirming genuine physical restrictions, rather than reinforcing permanent travel avoidance as the principal coping strategy.

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A patient declines prolonged exposure because of concerns about session demands but wants treatment. Explore those concerns, explain other recommended trauma-focused options, and arrange cognitive supports rather than closing access to care after the first declined approach.

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A patient describes an intention to die that evening, access to a firearm, and inability to resist acting. Maintain direct supervision, restrict access to the weapon, and arrange urgent psychiatric safety management rather than routine outpatient follow-up.

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A patient with a remote suicide attempt denies current intent, has no recent preparation, and demonstrates reliable safety-plan use. Assess present safety directly while maintaining follow-up for chronic vulnerability instead of automatically equating history with current crisis intensity.

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A patient agrees to a written safety plan but cannot recall its first step minutes later. Simplify and rehearse the plan, provide accessible cues, and involve suitable supports while reassessing whether independent safety is actually achievable.

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A headache is first documented several weeks after TBI. Reconstruct its onset, the date consciousness returned, and any discontinuation of medications impairing headache sensation or reporting. Later documentation alone establishes neither onset outside the main timing window nor an alternative qualifying anchor.

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A headache began the day after TBI and remains present four months later. Its course meets the persistent duration category, while its intensity, associated symptoms, medication use, and functional consequences still require separate assessment during follow-up.

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A patient with an established headache disorder has headache on 20 days per month and uses sumatriptan on 12 days per month for four months. With no better explanation, this meets the frequency and exposure framework for triptan-overuse headache. Non-opioid analgesic use on 12 days per month would not meet that class's 15-day threshold by itself.

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A patient has persistent insomnia despite avoiding evening caffeine and keeping a dark bedroom. Offer structured CBT-I rather than repeating sleep-hygiene advice as the complete treatment, while assessing coexisting pain, mood symptoms, and sleep-disordered breathing.

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A patient spends hours awake in bed checking the clock and worrying about sleep. Incorporate an individually safe stimulus-control plan into CBT-I, adapting nighttime movement recommendations to mobility and supervision needs rather than applying them mechanically.

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A diary shows six hours of estimated sleep during nine hours in bed. The approximate sleep efficiency is 67%, supporting review of sleep scheduling within CBT-I rather than assuming that an even earlier bedtime will solve the problem.

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A patient has witnessed breathing pauses and substantial daytime sleepiness despite a negative home study. Arrange laboratory polysomnography rather than concluding that the negative home result definitively excludes OSA or explains the symptoms as brain injury alone.

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A patient with prior stroke and suspected sleep apnea is offered routine home testing. Select laboratory polysomnography because the neurological history places the patient outside the uncomplicated group for which home testing is the preferred diagnostic alternative.

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A patient has a high apnea screening score and attributes poor concentration entirely to TBI. Explain that the score supports objective sleep evaluation, while a diagnostic study is needed before classifying the suspected breathing disorder with confidence.

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A patient develops a warm, swollen hip with steadily decreasing passive range after severe TBI. Investigate HO and competing causes rather than increasing antispastic medication solely because the limb has become harder to move during care.

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An ankle remains restricted during slow passive movement even when the patient is relaxed. Assess structural limitation and positioning needs, then set realistic goals instead of promising full dorsiflexion from a treatment directed only at neural overactivity.

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A patient who previously tolerated standing develops focal ankle swelling after a fall and refuses weight bearing. Reassess for fracture or soft tissue injury before resuming loading or forceful stretching as treatment for presumed increased tone.

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A patient has repeated stimulation-associated episodes of tachycardia, hypertension, sweating, fever, and extensor posturing with relative improvement between events. Document the clustered pattern and use structured PSH assessment while evaluating competing explanations for the episodes.

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A patient previously diagnosed with PSH develops sustained fever, hypoxemia, and a new respiratory examination abnormality between episodes. Investigate the new illness rather than attributing every physiological change to the established autonomic diagnosis during the rehabilitation stay.

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A patient has frequent small leaks, a distended lower abdomen, and a high residual after voiding. Address incomplete emptying and investigate contributors rather than selecting a bladder-suppressing approach solely because staff report frequent episodes of urinary incontinence.

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A patient empties the bladder adequately but forgets to request help and cannot manage clothing independently. Use timed assistance, clear cues, accessible toileting, and a documented bowel routine while training caregivers in the required level of support.

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A patient hospitalized for a week after TBI has persistent fatigue and reduced libido four months later. Include post-traumatic pituitary dysfunction in the assessment and arrange appropriate screening rather than attributing every symptom to deconditioning or depression.

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An acutely unwell patient after TBI develops unexplained hypotension and hypoglycemia. Obtain cortisol promptly if this does not delay care, administer empirical parenteral hydrocortisone, and involve endocrinology urgently while evaluating and treating other causes of instability.

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A patient develops new hypoxemia and fever after several difficult meals. Assess and manage the acute respiratory problem while arranging swallowing review and examining feeding practices, rather than assuming that antibiotics alone resolve the risk of recurrence.

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A patient is cleared for a modified diet but eats only a small portion because meals take an hour and assistance ends early. Review intake and weight, adjust feeding support, and reassess swallowing efficiency and nutritional needs.

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An adult with low-risk nonoperative TBI has no hemorrhage progression on follow-up CT and no other contraindication. Continue mechanical measures and initiate pharmacologic prophylaxis within the ACS 24-hour window. If hemorrhage progresses, reassess stability and timing rather than applying that window automatically.