Traumatic brain injury is an acquired brain injury following sudden traumas that cause damage to the brain. The injury may occur when the head unexpectedly and violently hits an object or when the skull is pierced by an object, which then enters the tissues of the brain. Every traumatic brain injury is different, and the symptoms can range from mild and moderate to severe depending on the level of the damage that has occurred to the brain. People with moderate or severe traumatic brain injuries may exhibit the symptoms; however, they may also experience a headache that only worsens or never ends, repeated nausea, vomiting, seizures, convulsions, inability to wake up from sleep, dilation of eyes (one or both), slurred speech, numbness in the extremities, increased confusion, loss of coordination, agitation, or restlessness. This assignment, therefore, evaluates the case of Mary following her accidental fall, the ensuing problems that necessitated the medical intervention, and the problems she encountered when she returned to school with a view for a better outcome.


Diagnosis of Marys Problem Using the DSM-5 Tool

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is an important manual with information regarding various psychiatric disorders. For more than 60 years that the manual has been in place, it has undergone numerous revisions with the current edition being DSM-5. Therefore, the current edition (DSM-5) is used to diagnose Marys problem. In DSM-5, there are injury characteristics and their durations that help to determine if a case is a mild, moderate, or severe TBI. The indicators of the injury include loss of consciousness, posttraumatic amnesia, as well as being disoriented and confused at the initial assessment. In mild TBI, loss of consciousness is always less than 30 minutes for a mild TBI, 30 minutes to 24 hours for a moderate TBI, and more than 24 hours in case of a severe TBI. Likewise, the duration of posttraumatic amnesia is less than 24 hours for a mild TBI, 24 hours to 7 days for a moderate TBI, and more than 7 days if a severe TBI occurs. Finally, there is a disorientation and confusion during the initial assessment based on Glasgow Coma Scale, which is between 13 and 15 for a TBI that is mild, 9 to 12 for a TBI that is moderate, and 3-8 for a severely expressed TBI.

Mary seems to be suffering moderate TBI because severity classification for individuals with moderate TBI based on loss of consciousness is between 30 minutes to 24 hours. In this case, Mary remained unconscious for less than 24 hours before finally waking up. In fact, by the following morning, she was fully awake and even recognized and weakly responded to her parents, who had been with her throughout the night. Besides, the hospital released her to go home after several days, but conducted a follow-up after one week. In DSM-5, individuals with a moderate TBI may present with posttraumatic amnesia for between 12 hours to seven days.

The other symptoms of moderate TBI include seizures, photosensitivity, irritability, depression, aggression, sleep disturbance, fatigue, hyperacusis, and apathy. Mary, for instance, is very irritable and aggressive based on how she bangs the door in anger to let her parents know that she would not be going to school the following day. Furthermore, her apathy and fatigue become evident when she decides to lock herself in her room, complains of being exhausted, and sleeps the whole afternoon until she had to be called for dinner several times. The learning difficulty that Mary encountered on her return to school could have been due to neurological or sensory disorders. People suffering from moderate TBI may experience deterioration in their interpersonal relationships, which is evident in Marys case. She indicated that she did not want to see her friends at school anymore.

Using the Glasgow Coma Scale to Measure Marys Initial Level of Unconsciousness and Her Later Level of Consciousness When She Woke Up in the ICU

The Glasgow Coma Scale (GCS) is a tool that is widely used to describe the degree of consciousness in a person that has suffered a traumatic brain injury. The tool has a scoring system that makes it possible to gauge the severity of brain injury. Importantly, the reliability and objectivity with which the recording is done for the initial and subsequent level of consciousness after a brain injury makes the tool very valuable. Mary woke up after three hours in the ICU but could only moan incoherently and move with restlessness. With this kind of response, she scores 2 for verbal response. Next, Mary responded to strongly presented verbal and tactile stimuli by opening her eyes briefly. Therefore, based on the GCS criterion of eye opening, she scores 3, because her response came only after she shouted a request. Likewise, she was able to move her finger upon request, but she could not speak; therefore, on best motor response, she scores 6 because she was able to obey a two-part request. In total, Mary scores a total of 11 on the GCS scale, meaning that she had suffered moderate traumatic brain injury.

The Using a Pre-Morbid Measure of Functioning in Determining Marys Pre-Morbid Level of Intellectual Functioning

Cognitive deficits in patients with brain damages are measured indirectly by predicting premorbid ability. The National Adult Reading Test (NART) is useful in the estimation of a persons premorbid level when it comes to intellectual ability. Importantly, the test entails reading out aloud a set of 50 words considered to be irregular in their grapheme-phoneme correspondences. The responses provided are scored individually as correct or incorrect based on the pronunciation. The result of the score is then used in developing a premorbid intelligence quotient (IQ) estimate. Based on the existing school records, Mary was academically in the top quarter of her class, meaning she must have had high IQ before the injury. Therefore, Marys intelligence after this injury needs to be measured based on her ability to measure correctly or incorrectly the 50 words that are provided in the NART list. The NART is characterized by a split-half reliability as well as a consistent test-retest reliability. Likewise, the test helps in providing an approximate general pre-morbid intelligence quotient where the Weschsler Adult Intelligence Scale-Revised (WAIS-R) is tested. Lastly, the test is resistant to neurological and psychiatric disorders, particularly when measuring premorbid ability. The Estimated Full Scale IQ is determined by the formula 127.7 -0.826x NART error score while the Estimated Verbal IQ is determined by 129-0.919x NART error score, and the Estimated Performance IQ is determined by 123.5-0.645x NART error score.

Assessment of Marys Post Injury Intellectual Ability Using the WAIS-IV Assessment and the Deficits Pre-and-Post Injury Performance

Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) is frequently used to test intelligence for older adolescents and adults. The test measures general intelligence using subsets, each of which indicating and estimating intelligence. The new subsets of WAIS-IV include visual puzzles, figure weights as well as cancellation. Importantly, the WAIS-IV relies on ten essential subsets in order to produce the Full Scale IQ (FISQ). Verbal Comprehension Index and Perceptual are each made up of three subsets while the Working Memory Index and Processing Speed Index are both made up of two subsets each.

The WAIS-IV, particularly the verbal comprehension index, can be used to compare Marys comprehension ability before and after the injury. Similarly, the working memory and processing speed index can be used to gauge her level of processing information before and after the injury. The other subsets of the WAIS-IV that can be helpful for assessing Mary include her ability to complete pictures, numbering letters sequentially, performing arithmetic, matrix reasoning, coding, and symbol search. In Marys case, it is possible to observe deficits in her verbal comprehension and memory processing when comparing her pre- and postinjury performance. It is also likely that Mary may have deficits in her ability to search certain symbols, perform certain arithmetic and matrices, and her processing speed is likely to remain slow, which is evident in her inability to complete class assignments in time just like the other students managed.

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The Use of Assessments of Cognitive Speed to Determine why Mary Cannot Keep Up in Class

One of the assessment tools for assessing cognitive speed is the Trail Making Test with parts A and B. The parts are 25 consisting circles, with their distribution done over a paper sheet. Part A has circles numbered 1 to 25, and patients are required to draw lines joining the numbers in ascending order. However, in part B, the circles contain letters and numbers, and the patient is expected to join the orders in ascending order, but alternating the numbers and the letters. In this case, Mary would be advised to connect the circles as quickly as she can without lifting the pencil from the paper. Errors would affect her scores; and if she cannot complete the test in five minutes, then she would be discontinued. The time she takes to complete the test would be used to determine her level of impairment. Importantly, the higher the score, the greater is her level of impairment. For instance, in trail A, 29 seconds is the average time while more than 78 seconds is considered defiant. In trail B 75 seconds is considered average while more than 273 seconds is considered defiant.

In the digit-symbol substitution test, Mary would be required to translate different symbols into digits based on a key of symbol and digit pairs provided on the task sheet. Mary would be expected to match the numbers with graphical symbols as quickly as she can after reading the instructions. The symbols will appear one after the other, and Mary will then enter the number that corresponds to the symbol. The test will end automatically after 90 seconds, and correct responses will be calculated. The maximum amount that Mary will have completed correctly will help to estimate her perceptual information speed. Paced Auditory Serial Addition Test (PASAT) will be used to determine Marys auditory information processing speed and flexibility. Administration time will be between 10 and 15 minutes. Marys auditory information processing speed will be determined based on the number of correct answers that she will have answered from the possible 60 answers that she will be expected to give. The outcome will help to determine if she had an auditory information processing problem, and therefore, was not able to keep up in class.

Recommendations for Rehabilitation of Mary

Family support, counseling, and education will be vital in Marys case for a prolonged period. Such effort will enable her to eventually return to maximum independence as well as participate in community activities that she engaged in before the injury.

Continued observation by appropriate staff will be critical for the rehabilitation of Mary. Through such observation, the caregiver will be able to identify unique changes that may have recurred during the recovery process.

Mary should continue receiving outpatient therapies in order to maintain and enhance her recovery. The therapies must, however, be prescribed only by her medical team.


The patient may require surgery to repair or remove raptured blood vessels or bruised brain tissues. Apparently, Marys disability will be based on the level and location of the injury, age, and her health condition. Some of the problems that Mary has gone through include cognition, sensory, communication, and behavior changes.


This case has provided an opportunity to understand traumatic brain injury in details. TBI can be mild, moderate, or severe depending on the symptoms that patients present with. In Marys case, for instance, the various assessment tools used for diagnosis have revealed that she suffered moderate TBI. Even though she has so far not managed to cope in class, various tools that have been used to assess her condition such as NART, WAIS-IV, Trail Making Test, digital-symbol test, and PASAT test are all useful in coming up with an appropriate rehabilitation and management strategy to enable her cope at home and in school.