Sample TBI Case Related Medical Report
A Life Care Plan (LCP) is a comprehensive document developed by a certified professional—often a Legal Nurse Consultant, Life Care Planner, or medical expert—that outlines the current and future medical and supportive care needs of an individual who has experienced a catastrophic injury or chronic illness.
It is often used in legal cases involving personal injury, medical malpractice, workers’ compensation, or disability claims.
Case Details
Case Summary
Traumatic Brain Injury (TBI)
Claimant
John Doe
Date of Injury
January 15, 2023
Mechanism of Injury
Motor Vehicle Collision (MVC)
Referral Source
Plaintiff Attorney
Date of Evaluation
June 1, 2023
Evaluator
Jane Smith
DNP, RN, CNLCP, CLCP, LNCC
Background & History
John Doe, a 42-year-old right-handed male, sustained a moderate traumatic brain injury as a result of a high-speed rear-end motor vehicle collision. The claimant was restrained and reportedly lost consciousness at the scene for approximately 2 minutes. Emergency Medical Services (EMS) noted a Glasgow Coma Scale (GCS) score of 12 upon arrival. He was transported to the local trauma center for further evaluation and treatment.
Medical Findings
Initial CT scan of the head revealed a right temporal contusion and small subdural hematoma without midline shift. The claimant was admitted to the ICU for monitoring and discharged after 3 days of observation. He reported ongoing headaches, dizziness, short-term memory loss, and emotional lability.
Neuropsychological evaluation two months post-injury documented deficits in attention, executive function, and working memory. MRI of the brain (performed 3 months post-injury) showed gliosis consistent with prior hemorrhagic contusion.
Current Complaints
- Persistent headaches (daily)
- Photophobia and phonophobia
- Difficulty concentrating and multitasking
- Mood swings, irritability, and depression
- Fatigue and poor sleep quality
Functional Impact
Mr. Doe has been unable to return to his pre-injury occupation as a warehouse supervisor due to cognitive and behavioral impairments. He now requires assistance with managing finances and household responsibilities. His wife has taken on a caregiver role.
Prognosis
Based on current literature and clinical experience, moderate TBI often results in permanent cognitive and emotional sequelae. While some improvement may occur over time, Mr. Doe is unlikely to regain his prior level of independence or occupational function without ongoing rehabilitation.
Recommendations
Continued outpatient neurology follow-up
Enrollment in cognitive rehabilitation therapy (2x/week for 12 months)
Psychiatric evaluation and counseling for depression and emotional regulation
Vocational rehabilitation assessment
Assistance with case management and support services
Prescription of anti-headache and mood-stabilizing medications
Legal/Forensic Considerations
The evidence supports that Mr. Doe’s current cognitive and emotional impairments are causally related to the motor vehicle accident. Medical documentation, imaging, and neuropsychological testing are consistent with a diagnosis of moderate traumatic brain injury with persistent post-concussive syndrome and neurobehavioral sequelae.
Within a reasonable degree of medical certainty, the claimant’s injuries are permanent in nature and will require lifelong medical oversight and supportive care.
