Post-Traumatic Head Injuries: Symptoms and Medical Documentation

Post-traumatic intracranial hemorrhage sequelae following a car accident?

Hello, doctor.
I was in a car accident four months ago, during which I lost consciousness and have no memory of the incident.
The diagnosis was: intracranial hemorrhage; cerebral contusion combined with skull fracture; facial bone fracture; bilateral ear contusion; and elbow contusion.
I was hospitalized for 8 days and rested for 2 months.
Currently, I experience occasional headaches, especially when there is a sudden change in weather or if I wash my hair and do not dry it immediately.
The headaches can be severe enough to last until the next day if I do not take pain medication.
I also experience occasional tinnitus, but it has improved significantly.
A month after the accident, I had almost complete hearing loss in one ear.
I consulted a doctor who mentioned that these are common sequelae of head trauma.
I asked the doctor to include this in my medical report, but he said that sequelae cannot be documented in the diagnosis.
Headaches, tinnitus, and other similar symptoms are considered sequelae.
I would like to understand the underlying reasons for this.
The doctor advised me to wear a hat to keep my head warm, yet he is reluctant to document the possibility of sequelae.
I am not trying to commit insurance fraud; the pain is severe enough that I need to take leave from work.
The at-fault party is unwilling to compensate, claiming they have no money and suggesting I file a lawsuit, stating it is my right.
I have inquired about my medical certificate, which only allows for 3 months of recovery and states that I need specialized care, but this is insufficient.
A headache specialist should indicate the possibility of sequelae for better clarity, but why is the doctor hesitant to write this? He has acknowledged that these are typical sequelae and mentioned that they may improve within a year.
Do I need to record this conversation?

Miss Yang, 30~39 year old female. Ask Date: 2019/07/22

Dr. Zhang Junwei reply Neurosurgery

Basically, having sequelae does not mean one cannot write; it depends on the physician's professional judgment.

Reply Date: 2019/07/22

More Info

Post-traumatic head injuries can lead to a variety of symptoms and complications, and your experience following the car accident is not uncommon. Given your history of intracranial hemorrhage, brain contusion, skull fracture, and facial bone fracture, it is understandable that you are experiencing ongoing symptoms such as headaches and tinnitus (ear ringing).

Understanding Your Symptoms
1. Headaches: After a traumatic brain injury (TBI), headaches can occur due to several reasons. They may be a result of tension, changes in intracranial pressure, or even post-traumatic migraines. The fact that your headaches worsen with weather changes or after washing your hair without drying it suggests that environmental factors and possibly stress or tension are contributing to your discomfort.
2. Tinnitus: The ringing in your ears could be related to the trauma you experienced. Tinnitus can arise from damage to the auditory pathways or inner ear structures, which can occur during head injuries. It’s not uncommon for individuals to experience hearing changes or tinnitus after such injuries, and while it may improve over time, some individuals may continue to experience these symptoms.

3. Cognitive and Emotional Effects: It’s also important to note that TBIs can lead to cognitive changes, emotional disturbances, and sleep issues. These can manifest as difficulty concentrating, mood swings, or increased sensitivity to stress.

Medical Documentation and Aftermath
Regarding your concerns about medical documentation and the physician's reluctance to note potential long-term effects or sequelae in your medical records, this is a complex issue. Physicians often have to balance clinical observations with legal and insurance implications. Here are a few points to consider:
- Medical Documentation: Physicians typically document the immediate effects of an injury and the treatment provided. Long-term sequelae can be more challenging to predict and document, as they may vary significantly from one patient to another. While your physician may acknowledge that headaches and tinnitus are common after such injuries, they may refrain from labeling them as "sequelae" or "post-concussive syndrome" due to the potential for legal ramifications or the difficulty in establishing a direct cause-and-effect relationship.

- Insurance and Legal Considerations: In cases involving accidents, insurance companies often require specific language in medical documentation to process claims. If a physician states that you have long-term sequelae, it could potentially lead to disputes regarding liability or compensation. This may explain your physician's hesitance to include such language in your medical records.

- Seeking Further Evaluation: If your symptoms persist and significantly impact your quality of life, it may be beneficial to seek a second opinion from a neurologist or a specialist in brain injuries. They can provide a more comprehensive evaluation of your symptoms and help document any ongoing issues related to your injury.

Recommendations
1. Follow-Up Care: Continue to follow up with your healthcare provider regarding your symptoms. If headaches and tinnitus persist or worsen, further evaluation may be warranted, including imaging studies or referrals to specialists.

2. Symptom Management: Consider discussing management strategies for your headaches and tinnitus with your healthcare provider. This may include medications, physical therapy, or cognitive-behavioral strategies to help cope with chronic pain and discomfort.

3. Legal Advice: Given the complexities of your situation regarding compensation and the reluctance of the at-fault party to pay, it may be wise to consult with a legal professional who specializes in personal injury cases. They can provide guidance on how to proceed with your claims and ensure that your rights are protected.

In conclusion, while your ongoing symptoms are not uncommon following a traumatic brain injury, the documentation and management of these symptoms can be complex. It is essential to advocate for your health and seek the appropriate care and documentation to support your recovery and any potential claims related to your injury.

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