Situation: Our patient, Randy Adams, is back today. You remember that he is a 28-year-old patient of mine who suffered a concussion as the result of a motor vehicle accident about 2 weeks ago. Randy lost consciousness during the accident and was very confused, so we kept him in the hospital for 24 hours of observation. I referred him to neurology and behavioral health afterward. His vital signs are as follows: temperature, 37°C (98.6°F); heart rate, 60 beats/min; respiratory rate, 16 breaths/min; blood oxygen saturation, 99%; and blood pressure, 115/80 mmHg.

Background: Randy is a war veteran, and after the car accident, he thought that he was still in the war. I am concerned that he may be having some residual problems from his service. He mentioned he had been exposed to bomb blasts in a couple of incidents when he served. His wife, Joy, told me she would make sure he goes to his appointments. I’ve encouraged him to look into getting care at the Veterans Affairs (VA) hospital, but he has really resisted that. He has a history of migraines, which started after the deployment. Randy saw Dr. Naylor, the neurologist, in a follow-up consultation. Topiramate and sumatriptan were prescribed. Also, Randy is seeing a psychiatric nurse practitioner, who recommended mindfulness. He came in for his appointment last week, but at the incorrect time.

Assessment: I think he may have PTSD and maybe some neurocognitive problems from his exposure to blasts, but we need to make sure he’s recovering from this most recent head injury before we can help him with the other problems.

Recommendation: I’d like for you to reassess his symptoms using part B of the ACE form and compare his results with those from the forms that were filled out at the hospital and here last week. Please also administer the Primary Care PTSD Screen. Please do a Mini-Cog assessment on him, as well. I’d like to know the results before I see him and Joy today.