ACC884

Injury Details & Sequelae: On 15 October 2024, the client, [insert name], sustained a concussion following a fall while cycling. Initial symptoms included headache, dizziness, and nausea, with a symptom severity rating of 7/10. The client was assessed at the local emergency department and discharged home with instructions for rest and observation. The client reports a gradual improvement in symptoms over the past two weeks, but continues to experience some difficulties with concentration and fatigue. The client has not yet returned to work. List of relevant medications currently taken to treat concussion symptoms: (e.g. analgesia, anxiolytics, antidepressants, thiamine) (Include dosage and frequency.) * Paracetamol 500mg, as needed for headache * Ibuprofen 200mg, as needed for headache Risk Assessment: The client presents with several risk factors that may impact their progress, including a high symptom load, and vocational challenges. The client reports significant difficulty with returning to work and is concerned about their ability to fulfil their job duties. The client also reports some psycho-social issues related to the injury, including feelings of isolation and frustration. Previous Head Injuries: The client reports no previous head injuries. Previous Unexplained Loss of Consciousness / Seizures: The client reports no history of unexplained loss of consciousness or seizures. Current Health Concerns: The client reports no current health concerns or medical conditions. Mental Health: The client reports a history of mild anxiety, which has been well-managed with cognitive behavioural therapy. The client reports that their anxiety symptoms have increased since the injury and is seeking support to manage these symptoms. Psychological Symptoms from Concussion: The client reports experiencing increased anxiety, irritability, and difficulty with concentration since the concussion. The client reports that these symptoms are more severe than their pre-concussion psychological state. Alcohol and Drug Information: The client reports occasional alcohol consumption (1-2 drinks per week) prior to the injury. The client has abstained from alcohol since the injury. The client does not smoke or use recreational drugs. The client consumes 1-2 cups of coffee per day. Daily Activities: The client reports some difficulties with personal cares, including showering and dressing, due to fatigue and dizziness. The client is able to perform basic household responsibilities, but requires frequent rest breaks. The client reports that their usual leisure activities, such as cycling and reading, are limited due to symptoms. The client is not currently driving. The client is currently off work. The client lives with their partner. The client reports good support from their partner and family, but is concerned about the impact of their injury on their work.